53/1 Dis

Post a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.

P E R S P E C T I V E

Don't use plagiarized sources. Get Your Custom Essay on

53/1 Dis

Just from $13/Page

Order Essay

2358

Growing Ranks of Advanced Practice Clinicians

n engl j med 378;25 nejm.org June 21, 2018

Growing Ranks of Advanced Practice Clinicians

Growing Ranks of Advanced Practice Clinicians
— Implications for the Physician Workforce
David I. Auerbach, Ph.D., Douglas O. Staiger, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.

Throughout the history of mod-ern American medicine, phy-
sicians have made up the vast
majority of professionals who di-
agnose, treat, and prescribe medi-
cation to patients. Although de-
mand for medical services has
increased markedly over the years
(and is projected to grow more
rapidly as the population ages),
the physician supply has grown
relatively slowly. Increased dele-
gation of work, new technology,
and streamlined care processes
can help practices meet patient
needs with fewer physicians, but
still require an increasing num-
ber of health professionals.1

Physician supply is constrained
in the short run by long training
times and in the longer run by
medical school capacity and the
number of accredited residency
positions. Despite a 16% increase
in graduate medical education
(GME) slots in recent years, the
Association of American Medical
Colleges (AAMC) recently project-
ed that the supply of physicians
will increase by only 0.5% per
year between 2016 and 2030.

A growing share of health care
services are being provided by ad-
vanced practice registered nurses
(APRNs), particularly nurse prac-
titioners (NPs), who make up the
majority of APRNs, and by physi-
cian assistants (PAs). NPs and PAs
provide care that can overlap with
care provided by physicians (both
in primary care and increasingly
in other specialties), and the
AAMC recognizes this overlap in
its physician-demand forecasts.
The number of NPs and PAs is

growing rapidly, in part because
of shorter training times for such
providers as compared with phy-
sicians and fewer institutional
constraints on expanding educa-
tional capacity. Residencies aren’t
required for APRNs — though
organizations are increasingly
offering them — and education
programs have proliferated: ac-
cording to the American Associ-
ation of Colleges of Nursing, the
number of NP degree programs
(master’s or doctorate) grew from
282 to 424 between 2000 and
2016. Baccalaureate-prepared RNs
typically require 2 to 3 years of
graduate education to become
certified NPs. PA programs typi-
cally take 2 years and also don’t
require residencies. According to
the National Center for Education
Statistics, the number of PA de-
gree programs grew from 135 to
238 between 2000 and 2016.

These dynamics will have last-
ing effects on the composition of
the health care workforce and
on working relationships among
health professionals. To take a
closer look at these trends, we
estimated the number of full-time-
equivalent physicians, NPs, and
PAs between 2001 and 2016 using
data from the U.S. Census Bu-
reau’s American Community Sur-
vey, which included a roughly
0.4% sample of the U.S. popula-
tion between 2001 and 2004 and
a 1% sample between 2005 and
2016. Because the Census didn’t
identify NPs until 2010, we ob-
tained data on NPs from the Na-
tional Sample Survey of Regis-
tered Nurses from 2000, 2004,

and 2008. Figures were validated
using data from health profes-
sional associations. The final data
set includes 12,887 NPs, 12,801
PAs, and 166,103 physicians.

These data were used to proj-
ect the number of NPs, PAs, and
physicians through 2030 using
methods described in greater de-
tail elsewhere.2 Briefly, our model
estimates the number of provid-
ers of various ages in each year
as a function of both workforce-
participation patterns associated
with age and estimates of differ-
ences among birth cohorts in rates
of entry into each profession,
which ref lect institutional con-
straints. Our projections assume
that age-related workforce-partici-
pation patterns will remain stable
after 2016 and that the size of
the workforce for birth cohorts
that have not yet entered the labor
force will resemble that of the
five most recent cohorts. In the
case of physicians, to better cap-
ture the expansion in medical ed-
ucation and throughput in recent
years, we assume that the size of
future cohorts will resemble the
size of only the most recent (larg-
est) cohort. In our prior work,
this model has successfully fore-
cast health care workforce trends.2

As shown in the table, between
2001 and 2010, workforce supply
increased by roughly 150,000 phy-
sicians (an increase of 2.2% per
year), 27,000 NPs (an increase of
3.9%), and 44,000 PAs (an increase
of 7.9%). Between 2010 and 2016,
the combined increase in NPs and
PAs (79,000) outpaced the increase
in physicians (58,000), although

P E R S P E C T I V E

2359

Growing Ranks of Advanced Practice Clinicians
n engl j med 378;25 nejm.org June 21, 2018

the NP and PA workforces were
roughly one tenth the size of the
physician workforce in 2010. Dur-
ing this period, growth in the NP
supply accelerated to nearly 10%
per year, whereas growth in the
PA supply slowed to 2.5% and
growth in physician supply slowed
to 1.1%. The number of NPs and
PAs per 100 physicians nearly
doubled between 2001 and 2016,
from 15.3 to 28.2.

We project that these trends
will continue through 2030. The
number of full-time-equivalent
physicians is expected to continue
growing by slightly more than 1%
annually, as increased retirement
rates are offset by increased en-
try, whereas the numbers of NPs
and PAs will grow by 6.8% and
4.3% annually, respectively. Rough-
ly two thirds (67.3%) of practi-
tioners added between 2016 and
2030 will therefore be NPs or
PAs, and the combined number
of NPs and PAs per 100 physi-
cians will nearly double again to
53.9 by 2030. These shifts will
probably be even more pro-
nounced in primary care, where
physician supply has been grow-
ing more slowly than in other
fields and NPs tend to be more
concentrated.

The changing composition of
the workforce will have implica-
tions for provider teams. Primary
care providers, in particular, in-
creasingly work in larger groups
of professionals with varying back-
grounds and types of training. A
2012 national survey of primary
care NPs and physicians found
that 8 in 10 NPs worked in col-
laborative practice arrangements
with physicians and 41% of phy-
sicians worked with NPs — a
percentage that will probably grow
over time.3 As more states ex-
pand practice authority for NPs,
medical practices will have to ad-
just. A recent study of working
relationships between NPs and
physicians on primary care teams
in New York and Massachusetts
found that physicians, other staff,
and patients often confused the
roles and skills of various provid-
ers and that these misunderstand-
ings often led to practices under-
mining the productivity and
efficiency of NPs.4 Physicians,
NPs, and PAs will all need to be
trained and prepared for this new
reality.

Greater reliance on nonphy-
sician clinicians is unlikely to
threaten quality of care or increase
costs. There is growing evidence

that the primary care provided by
NPs and PAs is similar to that
provided by physicians, and a re-
cent national study of Medicare
beneficiaries found that the cost
of primary care provided by NPs
was significantly lower than the
cost of physician-provided care.5

As with other projections, our
findings are subject to some de-
gree of uncertainty. It is unlike-
ly that the physician supply will
grow more rapidly than we proj-
ect: the AAMC projects even slow-
er growth, the number of GME
slots is constrained, and even an
immediate expansion of medical
school capacity and training op-
portunities wouldn’t substantial-
ly affect the physician supply for
many years. Growth in the NP
and PA workforces is more un-
certain. Although shorter, more
flexible training requirements for
these providers have facilitated an
unprecedented increase in new en-
trants, growth rates could fall if
demand for nonphysician provid-
ers is lower than anticipated and
job-market prospects worsen.
Major changes are unlikely, how-
ever, given the expected increases
in demand for care, growing use
of team-based and interprofes-
sional practice, and the fact that

Provider Group No. of Full-Time Equivalents Average Annual Growth (%)

2001 2010 2016
2030

(projected) 2001–2010 2010–2016
2016–2030
(projected)

Physicians 711,357 862,698 920,397 1,076,360 2.2 1.1 1.1

Nurse practitioners 64,800 91,697 157,025 396,546 3.9 9.4 6.8

Physician assistants 44,282 88,047 102,084 183,991 7.9 2.5 4.3

* Based on data from the American Community Survey (ACS) and the National Sample Survey of Registered Nurses. Estimates
for NPs in 2001 are interpolated on the basis of data from the 2000 and 2004 surveys. Full-time equivalents are defined on the
basis of reported usual weekly hours worked and a 40-hour workweek for NPs and PAs and a 50-hour workweek for physicians.
NPs include a small number of certified nurse midwives who were not separately identified in the ACS because of their small
numbers. PAs in the ACS reporting an associate’s degree or less education were excluded. All estimates are based on sample
weights provided in each survey.

Historical and Projected Numbers of Physicians, Nurse Practitioners, and Physician Assistants.*

P E R S P E C T I V E

2360

Growing Ranks of Advanced Practice Clinicians
n engl j med 378;25 nejm.org June 21, 2018

NPs disproportionately serve ru-
ral and underserved populations,
whose needs would otherwise go
unmet.

Despite these uncertainties, it
is clear that patients will continue
to encounter more NPs and PAs
when they seek care. The shifting
composition of the health care
workforce will present both chal-
lenges and opportunities for med-
ical practices as they redesign
care pathways to accommodate
new payment methods, new in-
centives regarding quality of care,

and the demands of an aging
population.

Disclosure forms provided by the authors
are available at NEJM.org.

From the Center for Interdisciplinary Health
Workforce Studies, College of Nursing,
Montana State University, Bozeman (D.I.A.,
P.I.B.); the Department of Economics, Dart-
mouth College, Hanover, NH (D.O.S.); and
the National Bureau of Economic Research,
Cambridge, MA (D.O.S.).

1. Bodenheimer TS, Smith MD. Primary
care: proposed solutions to the physician
shortage without training more physicians.
Health Aff (Millwood) 2013; 32: 1881-6.
2. Staiger DO, Auerbach DI, Buerhaus PI.

Comparison of physician workforce esti-
mates and supply projections. JAMA 2009;
302: 1674-80.
3. Donelan K, DesRoches CM, Dittus RS,
Buerhaus P. Perspectives of physicians and
nurse practitioners on primary care practice.
N Engl J Med 2013; 368: 1898-906.
4. Poghosyan L, Norful AA, Martsolf GR.
Primary care nurse practitioner practice
characteristics: barriers and opportunities
for interprofessional teamwork. J Ambul
Care Manage 2017; 40: 77-86.
5. Perloff J, DesRoches CM, Buerhaus P.
Comparing the cost of care provided to
Medicare beneficiaries assigned to primary
care nurse practitioners and physicians.
Health Serv Res 2016; 51: 1407-23.

DOI: 10.1056/NEJMp1801869
Copyright © 2018 Massachusetts Medical Society.Growing Ranks of Advanced Practice Clinicians

The Graduate Nurse Education Demonstration

The Graduate Nurse Education Demonstration
— Implications for Medicare Policy
Linda H. Aiken, Ph.D., R.N., Joshua Dahlerbruch, B.S.N., Barbara Todd, D.N.P., and Ge Bai, Ph.D., C.P.A.

Despite decades of public and private investment, the United
States continues to have a short-
age of primary care capacity.
Only 2699 graduating U.S. medi-
cal students — about 17% of
graduates from allopathic and
osteopathic schools — matched
with primary care residencies in
2016.1 Studies show that nurse
practitioners (NPs) provide high-
quality primary care that is satis-
factory to patients, improves ac-
cess to care in underserved areas,
and may reduce costs of care.
But although Medicare spends
more than $15 billion annually
on graduate medical education
(GME),2 including training for pri-
mary care physicians, it spends
very little on clinical training
for NPs.

Medicare has contributed to
the cost of training nurses since
its inception, but NP programs
didn’t exist when Medicare was
enacted and such funding streams

were established. Modernizing
Medicare’s payment policies for
nurse training is highly relevant,
given the recent success of the
Graduate Nurse Education (GNE)
Demonstration.3 The $200 million,
five-site Centers for Medicare and
Medicaid Services (CMS) demon-
stration authorized under the
Affordable Care Act showed that
offering payments to Medicare
providers enabled more of them
to participate in clinical precept-
ing of advanced practice regis-
tered nurses (APRNs) and result-
ed in a substantial increase in
the number of new APRN gradu-
ates. More than 60% of training
took place in community-based
settings, and primary care NPs
accounted for most of the growth
in the number of new graduates.

The GNE Demonstration doc-
umented the success of a new
model of organizing and paying
for graduate nurse education in-
volving consortia of hospitals

and health systems, community
partners, and university nursing
schools managed by a single
Medicare hospital hub. Such con-
sortia were originally proposed
in 1997 by the Institute of Medi-
cine (now the National Academy
of Medicine) as a strategy for in-
creasing community-based train-
ing for physicians, but were not
implemented until the GNE Dem-
onstration. Of the five demonstra-
tion networks, three were state
or regional consortia covering
greater Philadelphia, the Texas
Gulf Coast, and Arizona. In great-
er Philadelphia — the largest con-
sortium — the Hospital of the
University of Pennsylvania served
as the designated hub for a re-
gional network that included all
health systems and hospitals in
the area, more than 600 com-
munity-based providers, and all
9 local university nursing schools
involved in training APRNs. This
model has many advantages. For

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.

ajn@wolterskluwer.com AJN ▼ February 2018 ▼ Vol. 118, No. 2 43

strategies for creating a more highly educated nurs-
ing workforce.

APIN GRANTEES
The National Advisory Committee for the APIN NPO
selected nine states—California, Hawaii, Massachu-
setts, Montana, New Mexico, New York, North Car-
olina, Texas, and Washington—to design and test
potential models of academic progression. All nine
states were already engaged in some aspect of aca-
demic progression, and each received a two-year,
$300,000 grant with the possibility of a second. The
RWJF and the NPO considered this a laboratory in
which results could be obtained, evaluated, and shared
within that four-year time frame; all grants concluded
by the end of 2016.

APIN funded efforts on two fronts: initiatives that
remove obstacles that keep nursing students from get-
ting their BSN—such as support for partnerships be-
tween universities and community colleges to allow
seamless progression from the associate’s degree (AD)
to the baccalaureate—and employment-focused part-
nerships between schools and health care facilities
that provide students with practice experience, pro-
mote greater use of the BSN, and create employment
opportunities.

APIN OUTCOME HIGHLIGHTS
All of the states involved in the program developed
strategies for removing obstacles that keep nursing
students from getting their BSN. Massachusetts, Mon-
tana, Texas, and Washington, for instance, developed

Moving Closer to the 2020
BSN-Prepared Workforce Goal

In 2010, the Institute of Medicine (IOM) released its groundbreaking report The Future of Nursing: Leading Change, Advancing Health. One
of the report’s recommendations was to increase the
proportion of the nursing workforce with a bachelor
of science in nursing (BSN) or higher degree to 80%
by 2020.1 When the report was released, approxi-
mately 50% of nurses in the United States had a
BSN or higher.2

Better use of the nursing workforce is one goal of
the Campaign for Action, a joint initiative of the Rob-
ert Wood Johnson Foundation (RWJF) and AARP,
created to transform health care nationally.3 Through
work conducted by the Center to Champion Nursing
in America, possible models for addressing the need
for more nurses to obtain a BSN were identified,4 and
the RWJF built on that structure in developing and
evaluating opportunities to accelerate change within
the nursing education system.

In 2012, the American Organization of Nurse
Executives (AONE)—one of the four members of the
Tri-Council for Nursing—was selected by the RWJF
as the National Program Office (NPO) for a new ini-
tiative, the Academic Progression in Nursing (APIN)
program, which was created to study the topic of
higher degrees and employment for nurses and de-
velop solutions. (Along with AONE, the Tri-Council
member organizations are the American Association
of Colleges of Nursing, the American Nurses Associ-
ation, and the National League for Nursing.)

Now, APIN has concluded a four-year project de-
signed to identify and develop the most promising

ABSTRACT
One of the recommendations of the landmark Future of Nursing: Leading Change, Advancing Health report
was to increase the proportion of nurses with a bachelor of science in nursing or higher degree to 80% by
2020. In 2012, the American Organization of Nurse Executives was selected by the Robert Wood Johnson
Foundation as the National Program Office for a new initiative—the Academic Progression in Nursing (APIN)
program—with the goal of identifying and developing the most promising strategies for creating a more
highly educated nursing workforce. This article discusses the findings of APIN’s four-year project.

Keywords: bachelor of science in nursing, nursing students, nursing workforce

SPECIAL FEATURE
By Tina Gerardi, MS, RN, CAE,

Pat Farmer, DNP, RN, FNP, APIN, and
Bryan Hoffman, MA

44 AJN ▼ February 2018 ▼ Vol. 118, No. 2 ajnonline.com

transfer agreements outlining the courses and credits
that will transfer between community colleges and
universities, which facilitates a smooth progression
from AD to baccalaureate.

The program in Massachusetts is known as the
Nursing Education Transfer Compact (NETC). It
simplifies the transfer of credits earned in an AD pro-
gram to an RN–BSN program. Prerequisites, general
education, and core curriculum courses are accepted
by participating programs statewide. Students apply-
ing to any public school and many private schools are
under the umbrella of the NETC after obtaining their
AD and passing the National Council Licensure Ex-
amination (NCLEX), assuming they have completed
the general education requirements defined in the
state’s credit-transfer policy, known as MassTransfer.
Students who have completed the AD with a grade
point average of 2.75 or higher receive additional ben-
efits through the NETC: the fee for admission to an
RN–BSN program is waived, no admission essay is
required, and preferential admission is offered.

Washington created a state-approved program, the
Direct Transfer Agreement/Major Ready Program
(DTA/MRP), an optional standardized curriculum for
AD programs that makes the transfer of credits easy.
Students at participating community colleges complete
coursework and receive a DTA/MRP AD. Having met
all criteria for entry into a baccalaureate nursing pro-
gram, as well as all general education requirements,
they are eligible for licensure and can apply to any in-
state institution that grants RN–BSN degrees. Students
must select institutions for both their AD and BSN
that participate in the DTA/MRP curricular pathway.
Once admitted, students can complete their BSN in
one year. The DTA degree program has been initiated
in 43% of Washington State’s community college RN
programs and in all in-state public and private RN–
BSN programs. In 2015–2016, approximately 600
AD nursing students were enrolled in these programs,
with about 300 expected to graduate in June 2017.
To date, 11 students have attained their BSN through
the DTA.

California, Hawaii, New Mexico, New York, and
North Carolina replicated successful arrangements
between community colleges and universities for use
in other areas of the state.

For example, California State University, Los
Angeles, initially developed partnerships with seven

community colleges, providing a pathway for AD
students to complete the baccalaureate within four
years through coenrollment. Students apply and are
selected by their AD faculty prior to the second se-
mester of coursework at the community college. Stu-
dents complete the first three years at the community
college, taking baccalaureate-level classes offered dur-
ing the summer sessions. The AD is awarded at the
end of year 3 and students must pass the NCLEX to
continue.

Similar programs were subsequently developed
across other areas of California. All programs feature
five core elements: dual admission, integrated curricu-
lum, shared faculty, the availability of a BSN one year
after attainment of the AD, and a plan for program
sustainability. The program currently involves 19 uni-
versity campuses and more than 50 community col-
leges. Known as the California Collaborative Model
for Nursing Education, the program is on track to add
nearly 1,200 new BSNs a year to the California work-
force. Eighteen percent of AD students in California

are dually enrolled. In addition, employment part-
nerships between schools of nursing and health fa-
cilities were an important part of the process for the
development of academic-progression strategies.

The Queen’s Medical Center on the island of Oahu
in Hawaii worked with the University of Hawaii
at Manoa to develop an on-site executive RN–BSN
program for its nurse managers. The on-site pro-
gram allowed managers to achieve their BSN and
subsequently become mentors for staff nurses, help-
ing them go back to school to obtain their BSN.

North Carolina’s Regionally Increasing Baccalaure-
ate Nurses program and New York’s Dual Degree
Partnership in Nursing (DDPN) program both em-
phasize the need for strong academic practice part-
nerships to ensure that students complete their BSN
courses after passing their NCLEX.

In New York, a striking example of the positive
impact a strong partnership between academic insti-
tutions and employers can have on student success
was seen at St. Joseph’s College of Nursing in Syra-
cuse. When AD students shared with their dean that
the part-time work requirements for health benefits
at St. Joseph’s Hospital Health Center hindered their
ability to complete their courses, the dean contacted
the chief nursing officer (CNO) at the facility to share
the students’ concerns. The CNO formed a focus

A commitment to the work and to one another represents

transformative change in the nursing-education community.

ajn@wolterskluwer.com AJN ▼ February 2018 ▼ Vol. 118, No. 2 45

group and asked the students what a realistic part-
time work schedule that allowed them to complete
their studies might be. Through the focus group, it
was determined that 16 hours per week would give
these new RNs the time they needed to meet the ac-
ademic requirements of the DDPN program.

The CNO worked to change hospital policy to
allow any employee enrolled in the final year of the
DDPN program to receive part-time benefits while
working a minimum of 16 hours per week. This
proved to be a win–win for the students and the
employer.

The NPO and the APIN learning collabora-
tive (among the grant states and other academic-
progression leaders) determined that the community
college–university partnership model showed great
potential. New Mexico provided visionary leadership
through its New Mexico Nursing Education Consor-
tium model, pilot testing a statewide curriculum to
increase the number of BSN-educated nurses in New
Mexico and mentoring many other programs as they
implemented the model. All participants recognized
that close collaboration and support from practice
partners are critical to success, and many worked to
develop mechanisms to foster these relationships.

Updated information on the increase in the per-
centage of nurses with a baccalaureate or higher de-
gree is available from the Campaign for Action, at
https://campaignforaction.org/issue/transforming-
nursing-education. Here are highlights of the posi-
tive changes that have taken place as a result of these
efforts:
• The percentage of the RN workforce with at least

a BSN increased from 49% in 2010 to 53.2% in
2015.

• The percentage of first-time NCLEX takers with
a BSN or higher increased from 39.3% in 2010
to 47.2% in 2015.

• The proportion of RN–BSN graduates, in relation
to all BSN graduates, increased from 30.6% in
2010 to 47.4% in 2016.
More information on APIN and the outcomes of

the grant can be found at www.academicprogression.
org.

COMMUNITY DEVELOPMENT
The creation of a national community of nursing ed-
ucators dedicated to smoothing the path from com-
munity colleges to universities is having a profound
impact. The collegial spirit of this community has
created a climate that invites frank discussion of
model strengths, weaknesses, and challenges. Prom-
ising practices from all areas have been shared and
consolidated. Working toward a common goal has
resulted in a fellowship and camaraderie that gener-
ate a commitment not only to the work but to one
another. This represents transformative change in the

nursing-education community. The addition of local
employers into the development, implementation,
and evaluation of these models has added to the
strength of the partnerships, while providing incen-
tives for the incumbent workforce to achieve their
BSNs.

NEXT STEPS
With the closing of the NPO on June 30, 2017,
the work toward national academic progression
continues through a new initiative called the Na-
tional Education Progression in Nursing Collabora-
tive (NEPIN). The collaborative evolved from a series
of meetings with Tri-Council members and other in-
terested parties, including the Organization for Asso-
ciate Degree Nursing (OADN), HealthImpact, the
Washington Center for Nursing, Western Governors
University College of Health Professions, the Univer-
sity of Phoenix, the University of Kansas School of
Nursing, the Center to Champion Nursing in Amer-
ica, and the Philip R. Lee Institute for Health Policy
Studies. The OADN Foundation will serve as the fi-
duciary and convener for the collaborative in part-
nership with the National Forum of State Nursing
Workforce Centers.

For additional information on NEPIN, contact
Tina Lear, NEPIN national program director, at tina.
lear@nepincollaborative.org. ▼

Tina Gerardi is executive director of the Tennessee Nurses As
sociation in Nashville. Pat Farmer is a research professor at
George Washington University School of Nursing in Ashburn,
VA. Bryan Hoffman is deputy director of the Organization for
Associate Degree Nursing in Seattle. The authors received com
pensation from the Robert Wood Johnson Foundation through
the APIN grant discussed in this article. Contact author: Tina
Gerardi, gerarditina@gmail.com. The authors have disclosed no
potential conflicts of interest, financial or otherwise.

REFERENCES
1. Committee on the Robert Wood Johnson Foundation Initia-

tive on the Future of Nursing, at the Institute of Medicine, ed-
itor. The future of nursing: leading change, advancing health.
Washington, DC: National Academies Press; 2011. https://
www.nap.edu/catalog/12956/the-future-of-nursing-leading-
change-advancing-health.

2. Health Resources and Services Administration. The registered
nurse population: findings from the 2008 National Sample
Survey of Registered Nurses. Washington, DC: U.S. Depart-
ment of Health and Human Services; 2010 Sep. https://bhw.
hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal .

3. Robert Wood Johnson Foundation. The case for academic
progression: why nurses should advance their education and
the strategies that make this feasible. Washington, DC; 2013
Sep. Charting nursing’s future.

4. Future of Nursing: Campaign for Action. Four models show
ing promise for educational transformation. Washington, DC:
Robert Wood Johnson Foundation, AARP; 2012 May 15.
https://campaignforaction.org/wp-content/uploads/2012/05/
Early_Findings_Education_Learning_Collaborative_May2012.
pdf.

Transforming Nursing Education

http://www.academicprogression.org

mailto: tina.lear@nepincollaborative.org

mailto: gerarditina@gmail.com

https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health

https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal

https://campaignforaction.org/wp-content/uploads/2012/05/Early_Findings_Education_Learning_Collaborative_May2012

Nurs Admin Q
Vol. 42, No. 3, pp.

231

–245
Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Engaging Employees
in Well-Being
Moving From the Triple Aim to the
Quadruple Aim

Barbara Jacobs, MSN, NEA-BC, RN-BC, CCRN-K;
Julie McGovern, MA, SPHR, SHRM-SCP;
Jamie Heinmiller, BS;
Karen Drenkard, PhD, RN, NEA-BC, FAAN

Anne Arundel Medical Center has been on a 3-year journey to improve employee well-being
with the assumption that employee well-being and employee engagement are interconnected.
Improvements in employee well-being will result in increased employee engagement and will
be a pivotal driver to assist the health system meet its goals. Historically, Anne Arundel Medical
Center successfully differentiated itself in the market by being the region’s high-quality, low-cost
provider of health services delivered through intense collaboration with patients and families. The
financial, quality, and patient satisfaction results are in the top percentiles nationwide. However,
as the pace of change accelerates and the organization faces increased pressure to improve
outcomes, keeping employees from becoming burned out and disengaged becomes an increasing
concern. The WellBeing framework was developed on the basis of the work of Tom Rath and
Jim Harter as the model to support Anne Arundel’s WellBeing work. The efforts around well-
being are comprehensive and impact all aspects of how work is conducted. Employee well-
being has been elevated to an equal third prong along with providing high-quality low-cost care
in a patient-centered environment. This focus on leading an employee WellBeing Program has
resulted in improved engagement scores at Anne Arundel Medical Center. Key words: employee
engagement, leadership, quadruple aim, WellBeing Program

W HEN ANNE ARUNDEL MEDICAL CEN-TER (“AAMC”) adopted its 10-year
strategic plan, “Vision 2020” in 2009, it was
developed around 5 strategic pillars: Qual-
ity, Community, Workforce, Growth, and Fi-
nance. The initial strategies tied heavily to
the Triple Aim of improving the health of
populations, improving the patient experi-

Author Affiliations: Anne Arundel Medical Center,
Annapolis, Maryland (Mss Jacobs, McGovern, and
Heinmiller and Dr Drenkard); and GetWellNetwork,
Inc, Bethesda, Maryland (Dr Drenkard).

The authors declare no conflict of interest.

Correspondence: Karen Drenkard, PhD, RN, NEA-BC,
FAAN, GetWellNetwork, Inc, 7700 Old Georgetown Rd,
Bethesda, MD 20814 (kndrenkard@gmail.com).

DOI: 10.1097/NAQ.0000000000000303

ence, and lowering the cost of care.1 Anne
Arundel Medical Center had and continues
to have excellent outcomes, regularly receiv-
ing statewide recognition for high patient ex-
perience scores as compared with the state
of Maryland, better than average turnover
scores, and being the first organization in
the country to be awarded the Organiza-
tion Patient Safety Certification by the Mary-
land Patient Safety Center and the Courte-
manche & Associates. The system continues
to grow and be a financially strong, indepen-
dent health system. In the early years of Vi-
sion 2020, AAMC strove to differentiate it-
self in the market by being the high-quality,
low-cost provider of health services delivered
through intense collaboration with patients
and families. Anne Arundel Medical Center

231

mailto:kndrenkard@gmail.com

232 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

adopted a culture of continuous performance
improvement by following Lean2 principles.
In addition, AAMC began to include patients
and families in all aspects of care delivery. By
2015, AAMC had 100 patient advisors actively
participating on system committees at every
level, including on the Board Quality Commit-
tee and Physician Peer Review Committee.

As the pace of change accelerated, and
AAMC faced increasing financial pressure
along with ever-changing reporting mandates,
concerns about staff fatigue and burnout sur-
faced. Goals associated with the workforce
pillar of the strategic plan focused on in-
creasing employee engagement and decreas-
ing turnover. Both were important goals but
neither did enough to address employee stress
and burnout. In 2014, Thomas Bodenheimer,
MD, and Christine Sinsky, MD,3 published an
article reporting that staff burnout and dissat-
isfaction are associated with lower patient sat-
isfaction, reduced health outcomes, and po-
tentially increased costs. They recommended
that organizations adopt the quadruple aim,
citing that the fourth aim, improving the work
life of health care clinicians and staff, is nec-
essary to achieve the triple aim.1

In this same time period, Gallup (2013)
published the State of the American
Workplace,4 reporting that overall, in all cat-
egories and all industry sectors, employee en-
gagement continues to remain at 30% across
the US workforce. They noted that the work
environment has a significant impact on em-
ployee well-being, and employees with poor

well-being were less engaged and more neg-
ative about the workplace. The Gallup study
reported that employees who had high well-
being were more likely to be agile and re-
silient, experience better health, and report
higher job performance. It was suggested that
making well-being an organizational strategy
could be a way to improve employee’s lives
while achieving organizational outcomes. Fur-
ther research about well-being led to the work
of Rath and Harter, published in the book
Wellbeing: The Five Essential Elements.5

Rath and Harter define well-being as “the com-
bination of our love for what we do each day,
the quality of our relationships, the security
of our finances, the vibrancy of our physi-
cal health, and the pride we take in what we
have contributed to our communities.”5 The
core concepts of well-being transcend coun-
tries, culture, and generations. For the pur-
poses of this article, definitions spelled out
in Table 1 are used to describe WellBeing at
Anne Arundel Medical Center. Rath and Harter
posture that organizations that invest in their
employee well-being will gain an emotional,
financial, and competitive advantage.5

The stressors at work were not the only
stresses facing AAMC employees in 2014. The
economy was improving, but in a national
study that year, 76% of Americans surveyed
cited personal finances as a leading cause
of their stress.6 The survey revealed that
many physician visits are related to financial
stress while resulting in increased health care
costs, prescription costs, and absenteeism.6

Table 1. Definitions of Well-Being at Anne Arundel Medical Center

Purpose WellBeing: Having something to do every day that is challenging and enjoyable. For most
people, it is their jobs that contribute to their purpose.

Social WellBeing: Having strong relationships and love in your life. Having a supportive work
environment with people who care about you and who you care about is critical for thriving
social well-being.

Financial WellBeing: This element is about managing your finances in a way that provides long-term
economic security.

Physical WellBeing: Employees with thriving physical well-being experience good health and have
enough energy to get things done on a daily basis.

Community WellBeing: Being engaged with the community where they live and work enhances an
employee’s overall well-being.

Engaging Employees in Well-Being 233

In addition, 69% of 2014 college graduates
left college with student loan debt. Between
2004 and 2014, students’ average debt had
increased 56%, from $18 550 to $28 950.7

Other research showed that people were
more isolated and not connecting enough.
This resulted in increased loneliness and
poor social well-being.8 One comment from
a survey participant was:

At one time, work was a major source of friend-
ships. We took our families to company picnics and
invited our colleagues over for dinner. Now, work
is a more transactional place. We go to the office
to be efficient, not to form bonds.8

By every measure, American workers were
less healthy than at any other period in our
history.9

It appeared that by focusing on WellBeing
there could be improvement in the lives of
employees while AAMC continued to meet
the goals expressed in the triple aim.

There was early concern that focusing on
employee well-being was getting the organi-
zation too involved in employees’ personal
lives. Questions were raised about what could
actually be done to improve employee well-
being. From the outset, AAMC leaders were
determined to take demonstrable action to im-
prove employee well-being as part of meeting
the hospital mission: “To enhance the health
of the people we serve.” Hospital employees
are part of the community being served, and
all stakeholders could see the direct correla-
tion between employee well-being and the
Vision 2020, “Living Healthier Together.” It
was recognized that adoption of a WellBeing
program would take careful thought and
preparation. To get started, executive leaders
participated in a retreat to immerse them-
selves in the WellBeing model. The retreat’s
objective was to help leaders understand
what it means to commit to employee well-
being and what outcomes they could expect
from a formal program. There was honest
dialogue about how work was impacting
each executive’s well-being. The discussion
centered on how individuals own their per-
sonal well-being and the need to make small

shifts to improve work-life balance. Each
executive committed to a personal action
plan. A significant outcome of the retreat was
recognition of the importance of executive
role modeling. As a team, executives adopted
several strategies to help with their own
work-life balance, knowing full well that the
changes they made would impact the larger
leadership team. These strategies were to

• reduce many meetings from an hour to
45 minutes in order to allow time for bio-
breaks, checking e-mail, and getting from
one meeting to the next;

• stop sending e-mails between 7PM and
7 AM and on weekends, unless it was ab-
solutely required;

• use texts and calls to reach a colleague (if
necessary) in the “off hours.” This would
reduce everyone’s need to constantly
check e-mail. It was acknowledged that
this was already a practice and which dif-
ferentiated routine contact from urgent
communication;

• role model well-being, while speaking
openly at meetings about individual
commitments to improve personal well-
being.

The rollout of the WellBeing program to
the employees was gradual, giving AAMC time
to test the model, build infrastructure, and
ensure support. Leaders monitored and rec-
ognized the model’s swift adoption by staff
and management as people saw relevance
to their lives. All management staff received
the book, Wellbeing: The Five Essential Ele-
ments by Tom Rath and Jim Harter.5 A com-
mittee was formed to conduct a needs as-
sessment to identify the organization’s well-
being strengths and opportunities for im-
provement. The human resources (HR) de-
partment reviewed its programs to determine
how they could be redesigned to support
well-being.

METRICS FOR SUCCESS

A key foundational strategy was to deter-
mine, in advance of the rollout, how well-
being would be measured and where the

234 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

results would be reported. Ten initial work-
force aims were identified. Each month a re-
port is shared at the quality committee of the
board of trustees. Each aim supports 1 or more
WellBeing element. For instance, there is an
aim to increase employee

Financial WellBeing

by increasing participation in the 401k plan.
Another metric is to increase Physical Well-
Being through increased sales of healthy food
at all organization cafeterias and coffee shops.
Purpose WellBeing has aims to increase the
number of BSN-prepared nurses and to in-
crease staff skills in Lean quality concepts.
The Community WellBeing aim is developed
around support for community service. Over
time, the workforce aims have evolved. For
example, feedback from employees who vo-
calized concerns about employee safety has
resulted in additional aims targeted at reduc-
ing injuries to employees caused by patients.

To get a baseline on employee engagement
and well-being, AAMC implemented a WellBe-
ing survey that included the Gallup Q12 and
Gallup’s Well-Being 5 View assessment.10 As
of 2018, AAMC has 3 years’ worth of data.
Each year, goals are set at the system level
as well as the department level to increase
employee well-being and engagement. In ad-
dition, HR has built the concepts of WellBe-
ing into the core structural practices of re-
cruitment, staff and leadership development,
and goal setting. Some examples include the
following:

• WellBeing is integrated into the leader-
ship framework. Leadership behaviors at
AAMC are guided by the leadership frame-
work of “Team, Change, Business.” To
be a leader, each manager must excel at
managing his or her team by serving as a
coach, serving as a mentor, assuring staff
well-being, and encouraging team diver-
sity. Leaders are expected to demonstrate
changes in a transformational and inno-
vative way. The framework’s reference
to business means that leaders need to
understand the business of health care,
their role in it, and the basic skills of man-
agement. WellBeing concepts have been
woven into the “Team, Change, Business”

framework, making the commitment ex-
plicit.

• The electronic performance appraisal
and goal-setting system is used to have all
employees develop personal well-being
goals. By doing this, leaders have the op-
portunity to learn more about their teams.
They can better determine whether there
are ways to support staff members with
their goals. Employees determine how
much they want to share. Many have
found it beneficial and are getting sup-
port from their teams, as they seek to
improve their own well-being. Develop-
ment of personal well-being goals is vol-
untary and not part of the weighted per-
formance appraisal.

• The WellBeing concepts are woven into
orientation and into the leadership devel-
opment curriculum.

• Interviews for new leaders highlight the
importance of well-being for both them-
selves and their staff members. When
new leaders are onboarded, they receive
training on the well-being principles
along with an introduction to their role
in promoting employee well-being.

• Organizational goals to improve well-
being outcomes were set in year 2 and
have been applied to all leaders.

COMMITTEE FORMATION AND
PARTICIPATION

Once the commitment was made by the or-
ganization to embrace employee well-being as
a core differentiator, education was done with
key constituents. These included the nursing
leadership team and the Nurse Professional
Practice Council. Each presentation was well
received and resulted in volunteers to help
roll out the strategies. A structure was devel-
oped that supports well-being across the or-
ganization and includes staff at all levels. The
structure includes a steering committee and
5 subcommittees, 1 for each of the 5 Well-
Being elements. The steering committee is
led by the VP of HR, and there is an iden-
tified executive champion for each of the 55

Engaging Employees in Well-Being 235

committees. In addition, there are 3 additional
staff committees to represent night shift as
well as off-site stakeholders. Membership ap-
plications are taken through an intranet ap-
plication system in which employees can ex-
press their interest to serve on a committee
of their choice. Employees are asked, but not
required, to attend the meetings in person or
virtually. Conference line numbers are pro-
vided for meeting times. Members have be-
come champions within their departments,
constantly communicating efforts. Commit-
tee participation started at about 40 employ-
ees and has surged to more than 160 partici-
pants organization-wide during a 3-year time
period. There has been consistent participa-
tion due to expressed employee passion for
the work. Some participants like to work at
the organizational level while others focus at
the department level. The committees have
developed strategic objectives to guide the
committee work and set priorities. This step
has been pivotal in ensuring that work is
measurable and tied to the overall well-being
objectives. These objectives are shared in
Table 2.

Each year, the committees reevaluate goals
and develop actions for the coming year. Suc-
cessful programs are continued and unsuc-
cessful programs are revisited, either to revise
objectives or to develop new ones.

A big challenge for this work is prioritiz-
ing the interventions so that goals can be met.
The employees on these committees drive the
work and take ownership for the initiatives.
Because all stakeholders are involved in the
process, well-being actions have been imple-
mented for all shifts and sites. The commit-
tee members supporting the Eastern Shore
(approximately 25 miles from the main cam-
pus and part of the organization consisting
of physician practices and small ambulatory
sites) focused on Purpose, Social, and Physi-
cal WellBeing. They increased the amount of
education available to staff and held a fun,
competitive Field Day. They provide tips and
ideas about what individuals could do to im-
prove personal well-being.

The other regional committee serves a
larger population in 1 locale. Over the course
of 6 months, this group flourished. There is
consistent committee participation from 15
team members. The committee has planned
social gatherings, hosted a farmer’s market
over the summer months, implemented morn-
ing stretching sessions, reinstituted a popular
weight loss program, and planned a yearlong
Financial WellBeing series for employees. A
significant accomplishment was the addition
of food trucks to compensate for the lack of
a cafeteria. Staff members regularly comment
about the commitment to increase their well-
being and how they do not have to leave the
site to achieve it. The well-being scores in one
department at this site increased by 7% over
the course of 3 years.

The smaller number of staff on the night
shift creates challenges for bringing events
and programming to employees. The night
shift committee has developed creative ways
for programs designed for the day shift to be
successfully replicated for the night shift, in-
cluding specially designed physical challenges
and a stress reduction fair. The night shift
WellBeing champions have encouraged an
increase in social activities. They are coordi-
nating the financial series for this staff as well.
The committee challenges the organization to
include them in activities and has taken ac-
countability to help increase night shift mem-
ber participation at programs. The success of
the committees is driven by interested and
engaged leaders who can facilitate a philo-
sophical conversation, understand the limita-
tions of what can actually be achieved, and
encourage the committee to follow through
on planned actions. Employees do not have
to wait for someone else to make a change.
Changes can be made at the organization
level or department level through committee
work or by the individual. The steering com-
mittee, executive champions, and the VP of
HR are available to remove obstacles or to
guide actions so that they are aligned with
the overarching strategy and plans for the
organization.

236 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018

WellBeing
Element Strategic Objectives Completed Tactics over the last 3 y

Purpose Evaluate opportunities to
increase reward and
recognition for individuals
and departments

Provide additional
opportunities at all levels to
participate in career
development opportunities

Expand coaching and
mentoring throughout the
organization

Promote empowerment
philosophy

$250 000 scholarship program for
nonclinical employees; career
exploration fair for internal applicants
looking to explore opportunities or
transfer to new jobs; 100% e-mail access
for all employees; increased number of
employee classes; monthly newsletter to
all employees with education offerings;
leadership essentials program for new
leaders; panel sessions focused on
balancing work/life; national speakers on
WellBeing topics

Social Provide increased
opportunities for employees
to participate in
system-sponsored social
events

Develop strategies to increase
social WB at unit level

Provide education and support
to employees to learn impact
of others on their social WB

Thank You Card program; NYC Bus Trips;
Baseball Game; Book Club; Movie Nights;
Increased recognition training; Best
Friend at Work campaign; Art in the Café;
free tickets to local baseball and lacrosse
games; guidance to departments for how
to host their own department events
focused on Social WB; EAP hosted a class
on toxic people

Financial Increase participation in
retirement program

Increase financial education for
all staff

Financial education series; auto enrollment
for retirement plan; home buying course;
enhanced pharmacy benefits; partnership
with financial planners that offer
complimentary introduction and reduced
fee; financial fitness fair; vendor fair to
explore discounts; additional vendors
added to employee discounts; promotion
for EAP; combined leave benefit revision

Physical Promote healthy eating/
healthy food choices

Provide stress-reduction
programming

Promote health/opportunities
to stay active

Develop executive-level/
leadership involvement

Fresh fruit tastings with recipes in cafeteria;
cancer screenings and education for
employees; Wellness Wednesdays and
Fitness Fridays; Walk with an Executive
series; reduced soda and unhealthy
snacks; enhanced signage; healthy
cooking classes; New Year’s resolution
events; WellBeing+ (a wellness portal to
track challenges and overall health); free
seated chair massages; fryerless Fridays;
whole fruit at cafeteria registers; stress
reduction fair; stress reduction baskets to
departments

(continues)

Engaging Employees in Well-Being 237

Table 2. AAMC WellBeing Strategic Objectives and Tactics, 2015-2018 (Continued)

WellBeing
Element Strategic Objectives Completed Tactics over the last 3 y

Community Increase communication about
current AAMC community
activities

Create additional opportunities
for employees to participate
in community service

Recognize and support
employees for community
service

Food collection for local women’s shelter;
backpack collection and delivery for
foster children transitioning to homes;
sock drive; United Way campaign;
cultural diversity series; partnership with
project clean stream; CEUs for
community education; employee
hardship assistance fund; community
events at other well-being fairs (such as
packing lunches or can drives); more
than 200 000 h in community benefit
hours

Abbreviations: AAMC, Anne Arundel Medical Center; CEUs, continuing education; EAP, employee assistance program;
WB, WellBeing.

INVESTMENTS, ACTIONS, AND
OUTCOMES

The initial investment in WellBeing was
the implementation costs of adding the
WellBeing survey to the employee engage-
ment survey and the training of leaders on
WellBeing. A WellBeing manager was hired
to help facilitate the work of the committees,
conduct training, and oversee the survey and
action planning. The AAMC WellBeing budget
is small but it pays for 1 national external pre-
sentation a year as well as the supplies needed
to support committee activities. Significant
changes, such as alterations to the retirement
program, are funded through the annual ben-
efits budget. The majority of activities are low
cost and free. Whenever possible, WellBeing
concepts are interwoven into existing activ-
ities such as Nurses Week. Each WellBeing
element (Purpose, Social, Financial, Physical,
and Community) had specific activities that
have been implemented across the organiza-
tion. Each is described in more detail later:

Purpose WellBeing

There is a direct correlation to Purpose
WellBeing and high employee engagement.11

Anne Arundel Medical Center internal data
show that departments with high levels of

well-being are 12 times more likely to have
engaged employees. The Purpose WellBeing
committee has embraced career development
and has implemented an annual career de-
velopment fair. In addition, the committee
has raised awareness of the needs of entry-
level employees. As a result, an “Expanding
Horizons” program has been created in
collaboration with the Purpose WellBeing
committee to provide opportunities for career
exploration, career paths, and advancement
for entry-level staff within AAMC. Resources
have been invested to ensure that all staff have
e-mail access along with basic computer skills.
Entry-level staff now have access to career
coaching, basic skills assessment, and devel-
opment activities. Service department lead-
ers support and encourage their staff to take
advantage of these opportunities, which in-
crease promotion potential. The focus on Pur-
pose has resulted in the development of a ca-
reer ladder for patient care technicians in the
hospital. As a result, there are currently 35
patient care technicians on the ladder, and
several ancillary support service employees
have been promoted. System benefits include
reducing turnover and improving retention.

Data from the annual WellBeing survey in-
dicated the need to invest more in the de-
velopment of leaders. Programs have been

238 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

expanded to support leaders through the en-
tire life cycle of leadership. The AAMC “Lead
Academy,” an emerging leaders program, was
started in Nursing and was then expanded to
all leaders throughout the organization. In ad-
dition to learning basic leadership skills, Lead
Academy participants must complete a year-
long project. Several projects tie directly to
the WellBeing work, such as one study in-
troducing mindfulness to AAMC, and another
that researched the impact of sleep depriva-
tion on patient care.

Social WellBeing

This element has been widely embraced
at all levels of the organization. Under So-
cial WellBeing, the focus of the work is on
bringing employees together socially. It also
focuses on reducing stress, increasing em-
ployee safety, and reducing bullying. There
is overlap between Physical WellBeing and
Social WellBeing in developing and execut-
ing programs. Examples of activities include
well-loved programs such as bus trips to local
attractions, family movie nights, sports out-
ings, book clubs, and art nights. Employees
of all backgrounds help organize the events,
and participation is consistently high. Depart-
ments have worked hard to conduct and sup-
port social activities. Some combine social
activities with community support, such as
volunteering together at the local homeless
shelter.

One area of concern to AAMC team
members is that health care workers today
feel more threatened and less safe in the
workplace.12 Anne Arundel Medical Center
is able to leverage the WellBeing strategy
to address employee safety concerns. The
workplace safety committee has been rein-
vigorated. Members connect their work to
improving employee well-being. The most
recent AAMC Patient Safety Culture Survey
experienced a 16% increase in participation,
and 11 of the 12 composite areas went
up significantly. The composite score for
Handoffs and Transitions went from 43% to
77% and the composite score for Nonpunitive

Response to Errors increased from 41% to
72%. This is an example of how employees
are beginning to see the connection of
well-being to all facets of their work life.

Nationally, it has been well documented
that relentless change and ongoing pressure
to improve quality and reduce cost have
led to increased stress and dissatisfaction for
clinicians.13 The AAMC WellBeing Steering
committee has spearheaded more efforts to-
ward reducing stress within the organization.
The committee sponsored a speaker who
came to the organization to talk about burnout
and techniques to combat it. A stress reduc-
tion fair is hosted each year to give employ-
ees the opportunity to explore offerings such
as acupuncture, zero balancing, and mindful-
ness. Anne Arundel Medical Center also con-
tracts with local providers to offer employees
a discount on these services. One of the most
successful, yet simplistic, tactics has been to
create a stress reduction basket that contains
a plethora of stress reduction massage tools
along with tips for stretching. These baskets
rotate around the organization, and many de-
partments take matters into their own hands
by purchasing their own supplies for a “relax-
ation station.”

The medical staff has also championed
physician well-being. An annual physician
WellBeing conference attracts approximately
100 to 200 physicians. A physician well-being
survey is currently being implemented to
identify areas for improving provider well-
being. The physician lead for this work and
the manager of WellBeing are working to-
gether to create synergy between efforts.

Financial WellBeing

Financial WellBeing is the most difficult ele-
ment for leaders to address. Leaders across the
organization express discomfort when deal-
ing with this subject. There is not an expec-
tation that leaders need to discuss personal
financial planning with their staff. Rather,
leaders need to be aware of how financial
worries impact employee well-being and, po-
tentially, job performance. Leaders can be the

Engaging Employees in Well-Being 239

conduit to the growing library of information
the organization has to offer. The Financial
WellBeing committee arranged for a financial
series that offers opportunities for employ-
ees to learn about topics ranging from retire-
ment, home buying, credit card theft, improv-
ing credit scores, simple budgeting practices,
and loan forgiveness programs for health care
workers. Programs are offered in person and
online. The goal is to encourage individuals to
manage their financial resources (rather than
the misconception that the organization fo-
cusing on Financial WellBeing was going to
give everyone a raise). At the system level,
AAMC has taken significant steps to increase
employee Financial WellBeing. The Expand-
ing Horizon program was developed to en-
courage a career path for entry-level employ-
ees. As part of the evaluation of the Expanding
Horizon program, the minimum starting wage
was strategically increased by almost $3.00 an
hour over 2 years, with plans to continue to
invest as resources allow.

Gallup data indicate that individuals who
take steps to increase their long-term eco-
nomic security enjoy higher well-being over-
all. This information led to the system increas-
ing the retirement match an additional 1% and
automatically enrolling employees in the re-
tirement program with an auto escalation. To-
day there is a 95% participation in the retire-
ment program. This investment in Purpose
and Financial WellBeing for entry-level staff
has resulted in a 24% decrease in first-year
turnover.

A source of huge pride at AAMC is the im-
plementation of the Auxiliary Scholarship pro-
gram for entry-level staff. The volunteer aux-
ilians were educated about the principles of
WellBeing and then decided to build a pro-
gram for staff with the greatest need. The
Auxiliary donated $250 000 to start the pro-
gram. This competitive, scholarship program
is helping to build the pipeline for career
progression in the organization. Scholarship
winners are paid for full-time work but are
scheduled only 20 hours per week, allowing
them to enroll in school full time. All recipi-
ents are assigned a coach and a mentor. They

take classes that lead directly to a degree or
a certification for a job at AAMC. Once an
individual is close to successfully completing
his or her program, the desired department
works to hold a position for the employee. On
average, there has been an increase of 25% to
the employee’s base rate of pay in the schol-
arship group. Twenty-three employees have
successfully completed the scholarship in 7
fields. Currently, through the Foundation, 20
nursing scholarships are offered annually that
go beyond regular tuition reimbursement.

Physical WellBeing

Prior to the adoption of the WellBeing
framework, AAMC had a wellness initiative
called “Energize.” This successful program
provided on-site exercise classes and offered
weight loss reduction programs along with
healthy challenges. Since the adoption of
WellBeing as a program, participation in En-
ergize programs has increased by 75%, with
4300 employees participating in the program.
The Physical WellBeing committee expanded
the scope of Energize. Members work directly
with the dietary department to decrease the
sale of unhealthy food in the cafeteria. Sale
of healthy food now contributes 66% of all
revenue in system eateries. Soda has been
eliminated from the conference center, and
the sale of sweetened beverages has been re-
duced by 24%. In addition, a cooking class is
being hosted for employees. They can come
to the organization’s kitchen to learn how
to cook simple, easy, and healthy dishes at
home. They get to taste the food, too! Many
departments have developed programs and
challenges to promote a healthy lifestyle. The
benefits of these programs cross over to in-
creased Social WellBeing. A number of em-
ployees have made significant gains in improv-
ing their health. Their accomplishments are
celebrated on the internal AAMC WellBeing
Web site.

Community WellBeing

A few of the actions that were taken early
on were about building and expanding what

240 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

was already successful in the organization.
Two examples came directly from the
nursing division. Long before Community
WellBeing was being planned, the nursing
staff had organized a committee called the
Community Service Initiative. This group
planned sponsored community drives and
collections for local shelters and schools.
The Community WellBeing committee built
upon the nursing structure and expanded it
throughout the organization, thus allowing
more collections and drives. For many years,
the nursing staff did community outreach
to the local homeless shelter by providing a
health clinic twice a month. The Community
WellBeing committee expanded that support
by formally agreeing to support 2 families
annually as they transition from the shelter
to a home. Anne Arundel Medical Center
employees collect both new and used goods
that could outfit an entire house, including
furniture, kitchen supplies, and the hundreds
of basics it takes to make a home for a
family. A future challenge for the Community
WellBeing committee is to develop ways to
encourage employees to get involved in their
own communities and help leaders recognize
staff who do. The efforts around Community
WellBeing have increased employee pride in
working for AAMC. The Community WellBe-
ing score has experienced the largest increase
over the 3 surveys, with a 5% improvement.

NURSING LEADERSHIP AND WELLBEING
INITIATIVES

As the manager of the largest employee
base in the health system, the chief nursing
officer’s (CNO’s) involvement and passion for
this work are essential for the system’s success
in deployment. The AAMC National Database
of Nursing Quality Indicators (NDNQI) nurs-
ing satisfaction results were above benchmark
in all major categories, but it was clear from
employee feedback that the radical changes
occurring in health care and the stresses of
the workplace today have strained the staff.
The CNO must take an active role in educat-
ing nurse leaders on the positive impact of in-

creased employee well-being. He or she must
support the training and education needed to
properly support this type of change. One of
the core principles of a nursing Magnet hospi-
tal is to create a work environment supportive
of nursing professional practice and develop-
ment. The CNO should act as a role mode
or executive leader in this work by clearly
demonstrating to a large employee base that
the well-being of our staff is a priority for the
organization.

The development of the WellBeing initia-
tives, with the strong involvement of frontline
staff, has complemented work being done to
enhance Magnet performance and to maintain
a supportive work environment. In addition
to initiatives developed by the staff, national
experts were invited to provide educational
programs for frontline and leadership staff to
add to the WellBeing work. One, particularly
focused in Nursing, was centered on bullying
and incivility. Another was to provide tech-
niques for helping staff develop resiliency
in these times of change. Both courses were
received very positively by the staff and
augmented work being done through the
WellBeing committees.

An example of frontline nursing staff
contributions toward the development of
a project for one of our committees is the
“Petals of Purpose.” Discussions at the pro-
fessional practice committee have included
conversations about the personal impact of
remembering why individual nurses chose
the profession. These thoughts were shared
through the Purpose WellBeing committee
and resulted in a systemwide “petals of pur-
pose” project, which has resonated strongly
with the nursing staff. Employees were given
paper petals on which they wrote their pur-
pose, and each unit created a poster in which
these are mounted in their unit (see Figure 1).

Overall, this work supports the joy of
practice14 and is in line with the latest white
paper released by the Institute for Healthcare
Improvement13 on bringing joy back to the
workplace. This joy optimizes performance,
reduces turnover, and improves quality of
care. The 2017 IHI Framework for Improving

Engaging Employees in Well-Being 241

Figure 1. Emergency department “petals of purpose.” Used with permission from Anne Arundel Medical
Center.

Joy in Work summarizes the importance of
leaders by stating that “the leadership and
management practices designed to improve
joy in work are some of the most high-leverage
changes an organization can undertake since a
focus on joy in work simultaneously impacts
so many goals embedded within the Triple
Aim.”13 At AAMC, the success of this work
in each department was made a part of in-
dividual nurse leaders’ performance evalua-
tion. Regular pulse surveys are done to give
snapshot views of progress. Combining in-
formation from the employee engagement
survey and the NDNQI survey, nurse leaders
worked to develop action plans that tie the
work together in order to prevent duplica-
tion of plans. The pulse surveys ask 5 or 6

questions and allow monitoring the success
of work occurring on different units.

It is very important for staff to see the
CNO and all executive leaders as promoters
of this work. Discussing these initiatives with
large groups of nurses provides an excellent
opportunity to allow employees to see that
the organization is supportive of this work
to benefit them. The success of major cul-
tural change initiatives like this is dependent
on executive leaders actively demonstrating
their support. In partnership with the VP of
HR, nurse leaders can customize some of this
work for Nursing and then develop appropri-
ate training. Frontline leaders need to receive
excellent coaching so that they can support
changes in their individual departments.

242 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

IMPLICATIONS FOR BOARD MEMBERS

The CNO has an active role with HR to
underscore the importance and then the
success of the WellBeing work to the board of
trustees. When quality efforts and initiatives
emerge for health systems, the role of the
board of trustees is critical. Board member
engagement at the right level and at the right
time is essential for large-scale change efforts
to be successful. Appropriate board-level
engagements in understanding the strategic
priority, the expected outcomes, and the
necessary resources are all areas that board
members should be attuned to. “For the not
for profit hospital, the highest order stake-
holders are the patient and community”15(p59)

and by extension the community of care-
givers who provide that care. Board members

need to understand the impact of a healthy
employee population on the care of patients.
They should take the employees’ needs for
well-being into account when considering
resource allocation and strategy decisions.
Board roles in this work include activities
such as approving high-level organizational
goals and policies, overseeing project perfor-
mance at a strategic level through review of
performance metrics and results, and acting
as an advocate within the community for im-
portant initiatives.16 The management team
of AAMC has created “True North” metrics of
operational measures that include the Well-
Being efforts to improve workforce health.
Table 3 shares the extended well-being goals
and measures. Metrics are tracked monthly
and quarterly and are presented at each meet-
ing to both the quality and safety committee

Table 3. Workforce Goals and WellBeing Framework

AAMC Workforce Aims
WellBeing

Framework
Last Year

Result (2017)
This Year

Goal (2018)

Reduce year 1 turnover

Purpose
WellBeing

38% staff turnover 33% staff turnover

Increase number of diverse
candidates for leadership
positions

Purpose
WellBeing

Community
WellBeing

New 80%

Increase participation in
defined contribution plan

Financial
WellBeing

87% of staff
participating

92% of staff
participating

Increase employees
participating in fitness
challenges

Physical
WellBeing

Social WellBeing

4306 employees
participating

4737 employees
participating

Increase sales of healthy foods
in cafeteria

Physical
WellBeing

65% 67%

Reduce number of products
offering sugar by 65%

Physical
WellBeing

168 products in
cafeterias

59 products
in cafeterias

Reduce number of injuries
from combative patients

Physical
WellBeing

17 employee
injuries

14 employee
injuries

Financial
WellBeing

Maintain contributions level
to United Way

Community
WellBeing

$123 000 in
contributions

$120 000 in
contributions

Implement pulse surveys and
track improvement in Great
Places to Work survey

All WellBeing and
Engagement

Dimensions

New TBD

Abbreviations: AAMC, Anne Arundel Medical Center; TBD, To be determined.

Engaging Employees in Well-Being 243

of the board and the entire board of trustees.
The review and directional progress toward
annual goals are discussed in subcommittee
and committee meetings. Board members are
expected to ask knowledgeable and appro-
priate questions of management16 in order
to exercise the decision-making function and
the oversight function. The board members
serve as excellent external advocates for the
initiative. They realize that the approximately
4800 employees at the health system are
also members of the community, and that
their well-being has an impact on the ability
of the system to have a robust workforce
to provide high-quality, consistent care.
Annually, progress toward goals is reviewed,
and board approval is sought when setting
new targets. In addition, top leadership and
executive performance reviews are tied to
achievement of annual operating goals. In
this way, alignment occurs throughout the
organization, and the management team can
be rewarded for reaching goals.

EVALUATION AND NEXT STEPS

Anne Arundel Medical Center surveys for
both engagement and well-being at the
same time. The organization uses the Gallup
Q12 for staff engagement and the Gallup-
Healthways Well-Being 5 View to measure
staff well-being. Survey results show that work
groups that are high in engagement also tend
to have higher well-being scores. Thirty-eight
percent of employees are highly engaged at
AAMC, while 14% are disengaged. Employees
who are thriving in well-being tend to be more
highly engaged. The latest survey results show
that

• 74% of employees who are thriving in all
5 WellBeing elements are engaged;

• 48% of employees who are thriving in 3
of the 5 WellBeing elements are engaged;
and

• engagement drops to 10% for employees
thriving in zero WellBeing elements.

In addition, metrics for the WellBeing pro-
gram measure specific criteria reported to the
board of trustees (Table 3). Anne Arundel has

seen the following improvement since the
program began:

• Physical WellBeing: There has been an im-
provement in participation in physical ac-
tivity programs (called “Energize”) from
2466 participants in 2014 to 4298 partic-
ipants in 2017. This represents a nearly
75% increase. In addition, the system
had a 65% reduction in cafeteria prod-
uct offerings of sugared beverages. This
resulted in the elimination of 68 sugar
products.

There was an improvement in staff percep-
tion of feeling active and productive and hav-
ing physical health near perfect.

• Purpose WellBeing: Twenty-three em-
ployees enrolled in the “Expanding Hori-
zons” program that resulted in promo-
tions and pay increases. There was an
improvement in staff rating of “liking
what I do every day,” and learning
and doing something interesting every
day.

• Social WellBeing: Because of all of the ac-
tivities and social events that have been
conducted, there has been an improve-
ment in employee perception of receiv-
ing positive energy every day.

• Financial WellBeing: Over 3 years, par-
ticipation in defined contribution plans
rose from 75% to 95%. There was a de-
crease in employee perception of “being
worried about money in last seven days”
as well as an increase in employee per-
ception of “having enough money to do
everything.”

• Community WellBeing: Contributions to
United Way increased. An employee hard-
ship fund was launched as part of the
AAMC Foundation Annual Giving Cam-
paign, which gave employees the oppor-
tunity to designate funds to help fellow
employees during a financial emergency.
Employee perception was highest in “re-
ceiving recognition for helping to im-
prove the city where I live.”

Next steps for AAMC include a program
evaluation and further analysis of data. For ex-
ample, the organization will evaluate different

244 NURSING ADMINISTRATION QUARTERLY/JULY–SEPTEMBER 2018

workforce strategies and stratify them by gen-
eration. Data will be analyzed to see whether
there are differences in perception based on
age category. Another step will be to further
enhance the opportunities for employees to
more completely develop their own personal
well-being plan, along with individual mile-
stones that are easily tracked at the individual
level. Determination of the most valuable
elements of the WellBeing program from the
employee perspective will allow the leader-
ship team to further develop the most valuable
components of the program. In addition,
linking the WellBeing program outcomes to
employee engagement scores will ultimately
lead to reduced turnover and improved
employee satisfaction.17 Ultimately, these
metrics will be linked to organizational patient
satisfaction and quality-of-care outcomes.

CONCLUSION

As the work in WellBeing at AAMC has
evolved, one lesson learned has been that
the success of this initiative is dependent
on working with employees to own their
own WellBeing journey. The organization
is providing resources that employees can
choose to utilize as they desire. In this way,
employees are truly engaged in their health
and well-being. There is an expectation that
there will be an increase in the emotional
commitment that the employee has to the or-
ganization and to the “community we serve.”
The program will continue to be expanded.
It will include more frontline employee par-

ticipation, stronger frontline leadership, and
enhanced education about the importance of
whole-person well-being for employees. On-
going evaluation of progress will continue.
Opportunities for research in this space
exist, and data evaluation and linkages can
continue to be made by linking well-being
to employee engagement. Ultimately, this
improvement in employee well-being will
lead to better outcomes, as demonstrated by
documented studies that show that engaged
employees lead to better service, quality, and
productivity.6 Anne Arundel Medical Center
is well on its way to reaching the quadruple
aim through well-being of employees.

Engaged employees who feel cared for by
their employer through initiatives like our
WellBeing programs positively influence an
organization’s performance. The work done
at AAMC provides a framework, and gives
suggestions to others, around the process
of developing a robust employee WellBeing
program.

Many health care organizations have exclu-
sively focused on Physical WellBeing, under
the moniker, Wellness, and are now contem-
plating moving toward a more comprehensive
well-being strategy. Anne Arundel Medical
Center started out with a broader WellBeing
platform. Our wellness initiatives were placed
under Physical WellBeing as just one com-
ponent. This has allowed us to communicate
with our staff members in a direct way. We
have embraced the quadruple aim not just
in theory but through demonstrable actions,
actions that any leadership team can embrace.

REFERENCES

1. Berwick DM, Nolan TW, Whittington J. The triple
aim: care, health, and cost. Health Aff (Millwood).
2008;27:759–768.

2. Barnas K. Beyond Heroes: A Lean Management Sys-
tem for Healthcare. Appleton, WI: ThedaCare Center
for Healthcare Value; 2014.

3. Bodenheimer T, Sinsky C. From triple to quadruple
aim: care of the patient requires care of the provider.
Ann Fam Med. 2014;12(6):573–576.

4. Gallup. State of the American Workplace: Employee
Engagement Insights for US Business Leaders. An-

napolis, MD: Gallup, Inc; 2013. http://www.gallup.
com/file/services/176708/State%20of%20the%
20American%20Workplace%20Report%202013 .
Accessed April 6, 2018.

5. Rath T, Harter J. Wellbeing: The Five Essential Ele-
ments. New York, NY: Gallup Press; 2010.

6. Clarke A. $tress: a workplace epidemic. Benefits
Magazine. August 2014:32–35.

7. Camera L. 2014 graduates had the highest student
loan debt ever. US News and World Report. October
2015.

http://www.gallup.com/file/services/176708/State%20of%20the%20American%20Workplace%20Report%202013

Engaging Employees in Well-Being 245

8. Grant A. Friends at work? Not so much. New York
Times. September 2015.

9. Chenoweth D. Promoting Employee Well-Being:
Wellness Strategies to Improve Health, Performance
and the Bottom Line. Alexandria, VA: SHRM Foun-
dation; 2011:1–57.

10. Gallup, Inc. Gallup Q12 and WellBeing 5 assessment.
https://q12.gallup.com/public/en-us/Features. Ac-
cessed April 6, 2018; http://www.healthways.com/
well-being5. Accessed April 6, 2018.

11. Rath T, Harter J. The Economics of Wellbeing.
New York, NY: Gallup Press; 2010:14.

12. Phillips J. Workplace violence against health
care workers in the United States. N Engl
J Med. 2016;374:1661–1669. doi:10.1056/NEJMra
1501998.

13. Perlo J, Balik B, Swensen S, Kabcenell A, Lands-
man J, Feeley D. IHI Framework for Improving
Joy in Work. IHI White Paper. Cambridge, MA:
Institute for Healthcare Improvement; 2017. http://

www.ihi.org/resources/Pages/IHIWhitePapers/
Framework-Improving-Joy-in-Work.aspx. Accessed
April 6, 2018.

14. Gergen Barnett K. In pursuit of the fourth aim in
health care: the joy of practice. Med Clin North Am.
2017;101(5):1031–1040.

15. Bader BS. Distinguishing governance from manage-
ment, great boards, trustee services. Am Hosp Assoc
Publ. 2008;8(3):58–62.

16. Callender AN, Hastings DA, Hemsley MC, Morris
L, Peregrine MW. US Department of Health and
Human Services Officer of the Inspector General,
American Health Lawyers Association. https://
oig.hhs.gov/fraud/docs/complianceguidance/
corporateresponsibilityfinal%209-4-07 . Pub-
lished 2007. Accessed February 14, 2018.

17. Kruse K. What is employee engagement? Forbes.
https://www.forbes.com/sites/kevinkruse/2012/
06/22/employee-engagement-what-and-why/
#68d84b697f37. Published 2012. Accessed February
14, 2018.

https://q12.gallup.com/public/en-us/Features

http://www.healthways.com/well-being5

http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx

https://oig.hhs.gov/fraud/docs/complianceguidance/corporateresponsibilityfinal%209-4-07

https://www.forbes.com/sites/kevinkruse/2012/06/22/employee-engagement-what-and-why/#68d84b697f37

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

250

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8
250

Nurse Practitioner–Physician Comanagement:
A Theoretical Model to Alleviate Primary Care Strain

ABSTRACT
PURPOSE Various models of care delivery have been investigated to meet the
increasing demands in primary care. One proposed model is comanagement of
patients by more than 1 primary care clinician. Comanagement has been inves-
tigated in acute care with surgical teams and in outpatient settings with primary
care physicians and specialists. Because nurse practitioners are increasingly man-
aging patient care as independent clinicians, our study objective was to propose
a model of nurse practitioner–physician comanagement.

METHODS We conducted a literature search using the following key words:
comanagement; primary care; nurse practitioner OR advanced practice nurse.
From 156 studies, we extracted information about nurse practitioner–physician
comanagement antecedents, attributes, and consequences. A systematic review
of the findings helped determine effects of nurse practitioner–physician coman-
agement on patient care. Then, we performed 26 interviews with nurse practitio-
ners and physicians to obtain their perspectives on nurse practitioner–physician
comanagement. Results were compiled to create our conceptual nurse practitio-
ner–physician comanagement model.

RESULTS Our model of nurse practitioner–physician comanagement has 3 ele-
ments: effective communication; mutual respect and trust; and clinical alignment/
shared philosophy of care. Interviews indicated that successful comanagement
can alleviate individual workload, prevent burnout, improve patient care quality,
and lead to increased patient access to care. Legal and organizational barriers,
however, inhibit the ability of nurse practitioners to practice autonomously or
with equal care management resources as primary care physicians.

CONCLUSIONS Future research should focus on developing instruments to mea-
sure and further assess nurse practitioner–physician comanagement in the pri-
mary care practice setting.

Ann Fam Med 2018;16:250-256. https://doi.org/10.1370/afm.2230.

INTRODUCTION

W
ith imminent staffing shortages in the health care profession
and an increase in the volume of patients seeking primary care
services, patient loads are increasing rapidly, thus making it dif-

ficult for a single primary care professional to manage all patient care needs
effectively and efficiently.1-4 Therefore, policy makers are calling for new
primary care delivery models to meet the increased demands for care, espe-
cially due to patients with multiple comorbidities requiring more complex
primary care visits. Different models of care delivery have been proposed,
including team-based care, yet these models often have variability in task
allocation and professional roles.5 Identifying innovative models of care
delivery is increasingly important to meet these demands in primary care.

One proposed care delivery model includes having more than 1 pri-
mary care professional comanaging the same patient and sharing the work-
load responsibilities or care management tasks. Researchers have explored
comanagement of patients by 2 physicians in primary care,6 and by a phy-
sician and a nonphysician health care professional, such as a pharmacist.7,8

Allison A. Norful, RN, PhD,
ANP-BC1,2

Krystyna de Jacq, MSN, MPhil,
PHMNP-BC1

Richard Carlino, MD, FAAFP3

Lusine Poghosyan, RN, MPH, PhD,
FAAN1

1Columbia University School of Nursing,
New York, New York

2Columbia University Medical Center
Irving Institute for Clinical and Transla-
tional Research, New York, New York

3Mosholu Medical Group, Bronx, New York

Conflicts of interest: authors report none.

CORRESPONDING AUTHOR

Allison A. Norful, RN, PhD, ANP-BC
Columbia University School of Nursing
Columbia University Medical Center Irving
Institute for Clinical and Translational
Research
630 W. 168th St, Mail Code 6
New York, NY 10032
aan2139@cumc.columbia.edu

Downloaded from the Annals of Family Medicine Web site at www.annfammed.org.
Copyright © 2018 Annals of Family Medicine, Inc. For the private, noncommercial use of one individual user of the Web site.

All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.

WWW.ANNFAMMED.ORG

https://doi.org/10.1370/afm.2230

mailto:aan2139@cumc.columbia.edu

www.annfammed.org

mailto:copyrights@aafp.org

CO M A N A G E M E N T

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

251

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8
250
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8
250

No model, however, clearly describes the comanage-
ment relationship between physicians and advanced
practice nurses, such as nurse practitioners.

Nurse practitioners are registered nurses with
advanced master’s or doctoral degrees whose scope of
practice usually includes diagnosis and implementa-
tion of a patient care plan; regulations regarding the
scope of practice vary considerably among the states
regarding the need for physician involvement to treat
and prescribe.9 Policy makers, and the public, have
supported the expansion of nurse practitioners into
primary care,10 yet the comanagement relationship
between nurse practitioners and physicians remains
poorly defined. As more nurse practitioners are des-
ignated as primary care clinicians and practice inde-
pendent of physician oversight, a closer look at what
defines successful nurse practitioner–physician coman-
agement is warranted. The purpose of this article is to
present a theoretical model of nurse practitioner–
physician comanagement in primary care.

Definition of Comanagement
We define “comanagement” as 2 primary care profes-
sionals (a nurse practitioner and a physician) jointly
sharing the responsibility of all tasks needed to man-
age the health care of the same patient. These tasks
may include patient visits, such as for acute illness or
chronic disease management; pharmacologic manage-
ment, such as medication refills; diagnostic testing;
patient education, in terms of disease prevention or risk
reduction; and patient follow-up, such as interpretation
of laboratory values and making external patient refer-
rals based on test results. Comanagement also includes
sharing the administrative workload related to care
coordination, completing paperwork such as disability
or employment documents, and responding to patient
or caregiver phone calls.

History of Comanagement Model in Health Care
One of the first studies to examine comanagement
in health care was a large retrospective cohort study
about orthopedic surgery.11 This study examined
the effects of a surgeon and primary care physician
comanaging the same patient, and results showed posi-
tive associations between comanagement and shorter
hospital stays and fewer inpatient deaths. Further,
comanagement has increasingly become a common
practice across acute care organizations, and coman-
agement agreements have been implemented between
surgeons and other health care professionals.12 These
agreements clearly lay out responsibilities of each
party, communication methods and frequency, and
specific guidelines on resolution of disagreements. In
the outpatient setting, researchers have focused mainly

on comanagement by specialists and primary care phy-
sicians, or by pharmacists and physicians.7,13,14 These
studies showed that comanagement yields optimal clin-
ical outcomes, such as achieving blood pressure con-
trol. No published literature, however, has assessed the
effects of nurse practitioner–physician comanagement.

Similar Terms
Terms such as teamwork and collaboration are often used
interchangeably with comanagement. “Teamwork,”
however, is defined as a group of people working inter-
dependently to achieve a common goal9 and “collabora-
tion” is defined as 2 clinicians consulting with each other
and working concurrently by sharing knowledge and
expertise to achieve optimal patient care.15 Evidence is
clear about the benefits of team-based and collaborative
care,16 yet researchers have concluded that evidence is
lacking about comanagement approaches to care.17

Team-based care and collaborative care with nurse
practitioners often involve a hierarchy with team
members aligned in a vertical organizational struc-
ture based on profession or role. Vertical hierarchy
in an organization influences decision making and
subsequently may impede communication or increase
mistrust among team members from various profes-
sions.18 In contrast, comanagement involves a horizon-
tal organizational structure. Clinicians may comanage
across teams in a manner similar to a primary care
physician and a cardiologist comanaging the same
patient. These 2 physicians work within their own
teams within their practices, but overlap horizontally
to comanage the same patient. Within the same team,
an independent nurse practitioner may comanage the
same patient with a physician, in the same practice,
based on the urgency or complexity of a patient’s
needs. While research has found evidence of the
attributes of teamwork, including honesty, discipline,
creativity, humility, and curiosity,19 the literature fails
to capture the attributes of comanagement between
nurse practitioners and physicians.

METHODS
We built our model from the collective findings of 3
studies. First, using Walker and Avant’s method for
conceptual analysis,20 we conducted a literature search
in 5 electronic databases (Ovid Medline, CINAHL,
PubMed, Cochrane Review, and EMBASE) using the
following key words: comanagement; primary care;
nurse practitioner OR advanced practice nurse. A
total of 156 studies were reviewed. We extracted
information about nurse practitioner–physician
comanagement antecedents, relationships, defin-
ing attributes, and consequences. Next, using the

WWW.ANNFAMMED.ORG

CO M A N A G E M E N T
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

252

PRISMA framework,21 a system-
atic review was conducted to
determine the effects of nurse
practitioner–physician comanage-
ment and found an increase in
primary care clinician adherence
to recommended care guidelines
and improved clinical patient
outcomes.22 Third, we performed
in-person qualitative interviews
with nurse practitioners and physi-
cians to obtain their perspectives on nurse practitio-
ner–physician comanagement including the willing-
ness of primary care professionals to comanage care,
descriptions of the dimensions of comanagement,
and how nurse practitioner–physician comanagement
affects patient care. Twenty-six interviews were con-
ducted until data saturation was reached and no new
information was emerging from the interviews.22,23
Results of all 3 studies were triangulated to build the
conceptual nurse practitioner–physician comanage-
ment model.

Theoretical Underpinnings
Our approach to investigating nurse practitioner–phy-
sician comanagement was guided by the theoretical
underpinnings of Donabedian’s quality of care model24
(Figure 1). This model provided us with a frame-
work to evaluate the quality of comanagement. Two
researchers met weekly to discuss the findings from
the 3 studies and extract information about each of
the 3 dimensions of quality of care (structure, process,
and outcome). First, the researchers obtained informa-
tion about comanagement structure, which involved
the organizational and clinician resources or policies
that needed to be in place for nurse practitioners and
physicians to comanage the same primary care patient.
Next, we evaluated process, that is, how comanagement
was being practiced, what interactions were necessary,
and the interprofessional relationships between nurse
practitioners and physicians. Finally, we evaluated
outcomes, which included the results of our systematic
review and the reported perspectives of the primary
care professionals in our qualitative study.

RESULTS
Antecedents of Nurse Practitioner–Physician
Comanagement
The primary antecedent for effective nurse
practitioner–physician comanagement is nurse practi-
tioner autonomy. Various policy bodies regulate nurse
practitioner scope of practice and nurse practitioner
licensure, leading to a wide variablity.9 In addition

to national or state-based legislation that defines the
nurse practitioner scope of practice, nurse practitioner
responsibilities are often determined by organizational
policy.25 Despite the adoption of laws that allow nurse
practitioners to practice independently of physician
oversight, organizational or facility policy may inhibit
and restrict a nurse practitioner–physician comanage-
ment model. These restrictions are especially salient in
the primary care clinics that adopt a physician-led hier-
archical infrastructure in which the physician has the
final decision-making authority. In this case, the nurse
practitioners do not comanage the patient care but
exercise a limited role. Further, organizational climate,
and the culture of organizations, heavily influenced by
organizational management, often do not identify and/
or do not accept nurse practitioners as primary care
clinicians.26 In this situation, the organization does not
provide the same resources to nurse practitioners as
they do physicians.27 These resources include support
staff, such as medical assistant help, enough examina-
tion rooms for patient visits, involvement on decision-
making committees, and availability of learning oppor-
tunities.23,28 Our model focused specifically on coman-
agement in which nurse practitioners and physicians
were viewed equally as primary care clinicians, shared
equal responsibility for primary care patient manage-
ment, and were provided with equal resources.

Vital Attributes
Effective nurse practitioner–physician comanagement
has 3 vital attributes: (1) effective communication; (2)
mutual respect and trust; and (3) clinical alignment,
also known as a shared philosophy of care (Figure 2).

Effective Communication
Effective communication is a 2-way process in which
primary care professionals send a message that is easily
understood by the receiving party to prevent misunder-
standing and to save time. Comanagement communica-
tion is essential for developing the patient care plan,
managing a change in patient health status, individual-
izing patient goals, and delineating each primary care
clinician’s role in the care plan as part of coordinating

Figure 1. Theoretical Donabedian quality of care underpinnings.

• Nurse practitioners

• Physicians

• Primary care

What are the necessary
attributes of effective

comanagement?

How is comanagement
carried out?

What takes place within
the nurse practitioner–
physician interaction?

What are the implica-
tions of nurse prac-
titioner–physician
comanagement?

OutcomeProcessStructure

WWW.ANNFAMMED.ORG

CO M A N A G E M E N T
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

253

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8
252

patient care.29 When the nurse practitioner and physi-
cian who are comanaging a patient do not have direct
contact with each during their daily activities, the
use of secure messaging through an electronic health
record (EHR) or telephone calls are the most frequent
form of communication.23 Some EHR systems, however,
have been found to inhibit communication because
the nurse practitioner and physician documentation is
located in separate locations within the patient chart,
thus preventing them from seeing each other’s notes.23
The setting size and space often influence the type
of communication used, with smaller settings using
more informal modes of communication, such as text
messages.30 Comanagement communication must be
performed in a timely manner that is dependent on the
patient needs, such as a change in patient acuity level.
The communication needs to be reciprocal with equal
sharing of ideas, new patient information, and feedback
necessary to improve quality of care.31

Mutual Respect and Trust
Respect and trust among nurse practitioners and physi-
cians is the second critical element of comanagement.
This attribute increases over time as physicians and
nurse practitioners work together longer32; develop-
ing reciprocal trust and respect of each other’s role in
care delivery can take up to 6 months.30 By gaining
trust, physicians are less likely to feel that they need
to supervise or “double-check” the work of the nurse
practitioner, thereby reducing redundancy of docu-
mentation and diagnostic testing.

Traditionally, some physicians view nurse practi-
tioners as having an inferior role in primary care. This
viewpoint inhibits nurse practitioners from working to
their full potential and can create mistrust or resent-
ment. The physician must have an understanding of
the education, training, and scope of practice for nurse
practitioners to build trust during allocation of tasks
and responsibilities.25 The optimal combination of

Figure 2. Nurse practitioner–physician comanagement.

Nurse Practitioner–Physician Comanagement Attributes

Nurse practitioner autonomy (practice free from physician oversight)

Organizational policy enables comanagement care delivery

Antecedents

Power sharing

Shared responsibility of patient care

Ability to meet demand of patient care

Decreased individual provider workload

Increased continuity of care for patients

Increased patient access to care

Consequences

Method to resolve con� icting opinions

Clinical alignment

Similar work ethic

Mutual goals for patient care

Agreement on rationale for care plan

Knowledge of each other’s care
management expertise

Mutual respect of disciplines

Trust of each other’s care decisions

Recognition of each other’s contri-
butions to patient care

Timely exchange

Full access to each other’s patient care documentation

Organizational communication modes support comanagement

Mutual medical language

Shared
Philosophy

of Care

Effective
Communication

Respect
and Trust

WWW.ANNFAMMED.ORG

CO M A N A G E M E N T
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

254

nurse practitioners’ and physicians’ knowledge, culture,
and disciplines has the potential to positively contrib-
ute to the quality of patient care.

Shared Philosophy of Care
Physicians and nurse practitioners that we interviewed
agreed that each primary care professional must have
complementary practice styles that are congruent to
mutual goals for patient care, such as a shared philoso-
phy or having a clinical alignment in their patient care
plan.31 This shared philosophy includes approaches to
care management. Variability of approaches challenges
nurse practitioner–physician comanagement. For
example, one clinician may opt to treat mental illness
in primary care while the other clinician prefers refer-
ral to a specialist. Other examples include when to pre-
scribe an antibiotic or when to discontinue a patient-
specific treatment, such as pain management.

In the event of disagreement between primary care
clinicians regarding care decisions, discussion is vital.
However, a mutually agreed-upon protocol for conflict
resolution must be in place ahead of time to determine
who makes the final care management decision. This
protocol may vary by organizational policy or practice
setting. Clinical alignment also involves a similar work
ethic, such as time management styles. Without a simi-
lar work ethic, the workload may become unbalanced
and weighted toward 1 of the clinicians, potentially
leading to clinician burnout and increased strain. One
of the primary care professionals having a higher vol-
ume of daily patients than the other clinician may lead
to resentment, which may threaten mutual respect and
trust or communication, with the potential of indi-
rectly affecting patient care.

Consequences of Comanagement
At the level of the primary care professional, the pres-
ence of all 3 attributes of the model leads to clinician
cohesion. The stronger comanagement is, the greater
the potential for beneficial patient, clinician, and prac-
tice outcomes.22 One finding of our interviews was
that effective nurse practitioner–physician comanage-
ment alleviated individual clinician workload and the
strain to complete all recommended clinical care and
administrative tasks singlehandedly. A reduction of
primary care professional workload subsequently pre-
vents clinician strain, burnout, and fatigue, especially
with increased patient complexity. Nurse practitioner–
physician comanagement also enables interdisciplinary
collaboration between nursing and medicine, and better
care results from combining the experience and exper-
tise of clinicians from each discipline. Interdisciplinary
collaboration also promotes morale among team mem-
bers and leads to effective and efficient outcomes.33,34

Nurse practitioner–physician comanagement was
also found to increase patient access to care and pro-
mote continuity of care because patients have 2 clini-
cians familiar with their history and care needs.29,35
Longevity of patient and primary care professional
interactions is often described as a core value of high-
quality primary care.36,37 Further, fewer restrictions on
the scope of practice for nurse practitioners is associ-
ated with an increase in the number of nurse practi-
tioners practicing in rural or medically underserved
populations.38 Nurse practitioner–physician comanage-
ment in rural or medically underserved populations
allows primary care physicians to free time up for addi-
tional appointments, as well as provide patients with
more one-on-one time during patient visits to address
individual patients’ needs.3

DISCUSSION
More nurse practitioners are practicing as independent
primary care professionals, and developing innova-
tive approaches to integrate nurse practitioners and
physicians within and across team-based care models is
important. This article presents a theoretical model of
nurse practitioner–physician comanagement, including
the vital attributes of effective communication, mutual
respect and trust, and shared philosophy of care.

This novel theoretical understanding has several
potential uses. First, use of this model can help cre-
ate organizational policies needed to ensure the suc-
cess of nurse practitioner–physician comanagement.
When administrators, clinicians, and policy makers
promote effective comanagement, individual clinician
workload is reduced, thus preventing clinician strain,
burnout, and fatigue, especially with increased patient
complexity.23 Use of this model also enables increased
collaboration among clinicians who discuss and coordi-
nate the complex needs of patients, thereby providing
higher quality of care.34,39 Effective nurse practitio-
ner–physician comanagement also has the potential to
increase access to care because patients have 2 primary
care professionals familiar with their needs and plan of
care, thus promoting a continuity of care. If 1 clinician
is unavailable, the other can see the patient, preventing
a gap in access to care. By sharing the workload, nurse
practitioner–physician comanagement can lead to time
for additional appointments and/or more one-on-one
individualized attention to patient needs. We recom-
mend efforts toward interdisciplinary education within
academic institutions so that nurse practitioners and
physicians gain knowledge of each other’s disciplines
early on and learn strategies to comanage patient care
given the complexities of primary care delivery and the
identified strengths of each discipline.

WWW.ANNFAMMED.ORG

CO M A N A G E M E N T
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

255

A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8
254

Attention to individualized patient care is espe-
cially important as reimbursement mechanisms shift
from volume-based to value-based care and provider
payments are reliant on achieving targeted quality
outcomes.40,41 The combination of nurse practitioner
and physician expertise in comanagement can help
to ensure the highest quality of care. Several studies
included in our systematic review demonstrated a sig-
nificant difference in guideline adherence in favor of
nurse practitioners and physicians comanagement of the
same patient.22 Furthermore, evidence shows that nurse
practitioners in primary care professional roles have
equivalent or superior patient outcomes and are poten-
tially cost saving.42 This finding suggests the potential
of nurse practitioner–physician comanagement to be
more cost effective than 2 physicians comanaging care.
More cost-effective studies about nurse practitioner–
physician comanagement are warranted.

Lastly, despite the increasing numbers of nurse
practitioners and physicians who are already coman-
aging in practice, a substantial gap in the literature
remains about how organizations should design
comanagement models. More evidence is needed
about which care delivery models are the most effi-
cient and effective in primary care. Nurse practitio-
ner–physician comanagement demonstrates promise
to alleviate some of the primary care strain, but more
research is needed to produce empirical and gener-
alizable evidence about its impact on clinical, cost,
and organizational outcomes. Our theoretical model
provides health services researchers with knowledge
to operationalize nurse practitioner–physician coman-
agement in future studies.

A survey instrument is currently being developed
from this theoretical model and tested psychometri-
cally to enable measurement of nurse practitioner–
physician comanagement in practice and research
settings. This survey instrument, once validated, will
provide primary care physicians, practice managers,
policy makers, and researchers the ability to further
investigate nurse practitioner–physician comanage-
ment and its impact on patient or practice outcomes.

The 3 vital attributes from our nurse practitioner–
physician comanagement model—effective com-
munication, mutual respect and trust, and a shared
philosophy of care—cannot exist without the presence
of legal and organizational policies that recognize
nurse practitioners as autonomous primary care clini-
cians. Further, effective nurse practitioner–physician
comanagement requires adequate organizational
resources and the willingness of nurse practitioners
and physicians to comanage. Opposing opinions about
the autonomy of nurse practitioners and the drive for
physician-led hierarchical infrastructures have pre-

vented autonomous practice of nurse practitioners in
primary care.43 As long as such limitations exist, the
effective comanagement care model cannot be fully
investigated or implemented. We recommend empirical
measurement of nurse practitioner–physician coman-
agement for future research.

To read or post commentaries in response to this article, see it
online at http://www.AnnFamMed.org/content/16/3/250.

Key words: primary care; nurse practitioner; comanagement; theory

Submitted July 5, 2017; submitted, revised, November 1, 2017;
accepted November 30, 2017.

Funding support: This study was supported by the National Institute of
Nursing Research (T32 NR014205) and the National Center for Advanc-
ing Translational Sciences, National Institutes of Health (TL1TR001875).

Disclaimer: The content is solely the responsibility of the authors and
does not necessarily represent the official views of the NIH.

Previous presentations: This paper was presented at the Academy
Health Annual Research Meeting; June 25-27, 2017; New Orleans, Loui-
siana, and the 2016 Eastern Nurses Research Society Annual Meeting;
April 13-15, 2016; Pittsburgh, Pennsylvania.

References
1. Wu SY, Green A. Projection of Chronic Illness Prevalence and Cost Infla-

tion. Santa Monica, CA: RAND Corporation; 2000.

2. World Health Organization (WHO). Noncommunicable dis-
eases: progress monitor 2015. http: //apps.who.int/iris/bitstr
eam/10665/184688/1/9789241509459_eng ?ua=1. Published
2015. Accessed Jul 3, 2017.

3. Yarnall KS, Østbye T, Krause KM, Pollak KI, Gradison M, Michener
JL. Family physicians as team leaders: “time” to share the care. Prev
Chronic Dis. 2009; 6(2): A59.

4. World Health Organization. (WHO). World health statstics: monitor-
ing health for the sustainable development goals. http: //apps.who.
int/iris/bitstream/10665/255336/1/9789241565486-eng ?ua=15.
Published 2017. Accessed Oct 15, 2017.

5. Tiedeman ME, Lookinland S. Traditional models of care delivery:
what have we learned? J Nurs Adm. 2004; 34(6): 291-297.

6. Rose DE, Tisnado DM, Tao ML, et al. Prevalence, predictors, and
patient outcomes associated with physician co-management: find-
ings from the Los Angeles Women’s Health Study. Health Serv Res.
2012; 47(3 pt 1): 1091-1116.

7. Von Muenster SJ, Carter BL, Weber CA, et al. Description of phar-
macist interventions during physician-pharmacist co-management of
hypertension. Pharm World Sci. 2008; 30(1): 128-135.

8. Chen Z, Ernst ME, Ardery G, Xu Y, Carter BL. Physician-pharmacist
co-management and 24-hour blood pressure control. J Clin Hyper-
tens (Greenwich). 2013; 15(5): 337-343.

9. Brush JE Jr, Handberg EM, Biga C, et al. 2015 ACC health policy
statement on cardiovascular team-based care and the role of
advanced practice providers. J Am Coll Cardiol. 2015; 65(19):
2118-2136.

10. American College of Physicians. Nurse practitioners in primary
care: a policy monograph of the American College of Physicians.
https: //www.acponline.org/acp_policy/policies/nursepractitioners_
pc_2009 . Published 2009. Accessed Jul 3, 2017.

WWW.ANNFAMMED.ORG

http://www.AnnFamMed.org/content/16/3/250

http://apps.who.int/iris/bitstream/10665/184688/1/9789241509459_eng ?ua=1.

http://apps.who.int/iris/bitstream/10665/255336/1/9789241565486-eng ?ua=15.

https://www.acponline.org/acp_policy/policies/nursepractitioners_pc_2009

CO M A N A G E M E N T
A N NA L S O F FA M I LY M E D I C I N E ✦ W W W. A N N FA M M E D . O R G ✦ VO L . 1 6 , N O. 3 ✦ M AY / J U N E 2 0 1 8

256

11. Hinami K, Feinglass J, Ferranti DE, Williams MV. Potential role of
comanagement in “rescue” of surgical patients. Am J Manag Care.
2011; 17(9): e333-e339.

12. Cheng HQ. Comanagement: who’s in charge? AHRQ, Patient
Safety Network web site. https: //psnet.ahrq.gov/webmm/case/271/
comanagement-whos-in-charge. Published Jun 2012. Accessed Jul 3,
2017.

13. Weber CA, Ernst ME, Sezate GS, Zheng S, Carter BL. Pharmacist-
physician comanagement of hypertension and reduction in 24-hour
ambulatory blood pressures. Arch Intern Med. 2010; 170(18):
1634-1639.

14. Bowman BT, Kleiner A, Bolton WK. Comanagement of diabetic
kidney disease by the primary care provider and nephrologist. Med
Clin North Am. 2013; 97(1): 157-173.

15. Bridges S. Exploration of the concept of collaboration within the
context of nurse practitioner-physician collaborative practice. J Am
Assoc Nurse Pract. 2014; 26(7): 402-410.

16. Wen J, Schulman KA. Can team-based care improve patient satis-
faction? A systematic review of randomized controlled trials. PLoS
One. 2014; 9(7): e100603.

17. Harrington RA, Heidenreich PA. Team-based care and quality: a
move toward evidence-based policy. J Am Coll Cardiol. 2015; 66(16):
1813-1815.

18. Armstrong JH. Leadership and team-based care. Virtual Mentor.
2013; 15(6): 534-537.

19. Mitchell P, Wynia M, Golden R, McNellis B, Oku S, Webb CE, et al.
Discussion paper: core principles & values of effective team-based
health care. https: //www.nationalahec.org/pdfs/vsrt-team-based-
care-principles-values . Published Oct 2012. Accessed Oct 2017.

20. Walker L, Avant K. Concept analysis. In: Strategies for Theory Con-
struction in Nursing. New York, NY: Pearson; 2005: 37-54.

21. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Pre-
ferred reporting items for systematic reviews and meta-analyses:
the PRISMA statement. Ann Intern Med. 2009; 151(4): 264-269, W64.

22. Norful AA, Swords K, Marichal M, Cho H, Poghosyan L. Nurse
practitioner-physician comanagement of primary care patients: the
promise of a new delivery care model to improve quality of care.
[published online ahead of print April 25, 2017]. Health Care Man-
age Rev.

23. Norful AA. Nurse Practitioner-Physician Co-management of Primary
Care Patient Panels: Impact, Perspective, and Measurement toward a
New Delivery Care Model [dissertation]. New York, NY: Columbia
University; 2017.

24. Donabedian A. The quality of care. How can it be assessed? JAMA.
1988; 260(12): 1743-1748.

25. Schadewaldt V, McInnes E, Hiller JE, Gardner A. Views and experi-
ences of nurse practitioners and medical practitioners with collab-
orative practice in primary health care – an integrative review. BMC
Fam Pract. 2013; 14(1): 132.

26. Kilpatrick K, Lavoie-Tremblay M, Ritchie JA, Lamothe L. Advanced
practice nursing, health care teams, and perceptions of team effec-
tiveness. J Trauma Nurs. 2014; 21(6): 291-299.

27. Hall P. Interprofessional teamwork: professional cultures as barriers.
J Interprof Care. 2005; 19(Suppl 1): 188-196.

28. Almost J, Laschinger HK. Workplace empowerment, collaborative
work relationships, and job strain in nurse practitioners. J Am Acad
Nurse Pract. 2002; 14(9): 408-420.

29. Way D, Jones L, Busing N. Implementation strategies: “collabora-
tion in primary care—family doctors & nurse practitioners deliver-
ing shared care”: discussion paper written for the Ontario College of
Family Physicians. http: //citeseerx.ist.psu.edu/viewdoc/download?do
i=10.1.1.458.383&rep=rep1&type=pdf. Published May 18, 2000.
Accessed Oct 1, 2017.

30. Brault I, Kilpatrick K, D’Amour D, et al. Role clarification processes
for better integration of nurse practitioners into primary healthcare
teams: a multiple-case study. Nurs Res Pract. 2014; 2014: 170514.

31. Hallas DM, Butz A, Gitterman B. Attitudes and beliefs for effective
pediatric nurse practitioner and physician collaboration. J Pediatr
Health Care. 2004; 18(2): 77-86.

32. Schadewaldt V, McInnes E, Hiller JE, Gardner A. Investigating char-
acteristics of collaboration between nurse practitioners and medical
practitioners in primary healthcare: a mixed methods multiple case
study protocol. J Adv Nurs. 2014; 70(5): 1184-1193.

33. Al Sayah F, Szafran O, Robertson S, Bell NR, Williams B. Nursing
perspectives on factors influencing interdisciplinary teamwork in
the Canadian primary care setting. J Clin Nurs. 2014; 23(19-20):
2968-2979.

34. Grumbach K, Bodenheimer T. Can health care teams improve pri-
mary care practice? JAMA. 2004; 291(10): 1246-1251.

35. Freeman GK, Olesen F, Hjortdahl P. Continuity of care: an essen-
tial element of modern general practice? Fam Pract. 2003; 20(6):
623-627.

36. Freeman G, Shepperd S, Robinson I, et al. Continuity of care.
Report of a Scoping Exercise for the National Co-ordinating Centre for
NHS Service Delivery and Organisation R & D (NCCSDO). London, Eng-
land: NCCSDO; 2001.

37. Delva D, Kerr J, Schultz K. Continuity of care: differing conceptions
and values. Can Fam Physician. 2011; 57(8): 915-921.

38. Xue Y, Ye Z, Brewer C, Spetz J. Impact of state nurse practitioner
scope-of-practice regulation on health care delivery: systematic
review. Nurs Outlook. 2016; 64(1): 71-85.

39. Carless SA, De Paola C. The measurement of cohesion in work
teams. Small Group Res. 2000; 31(1): 71-88.

40. Asher AL, Devin CJ, Mroz T, Fehlings M, Parker SL, McGirt MJ.
Clinical registries and evidence-based care pathways: raising the
bar for meaningful measurement and delivery of value-based care.
Spine (Phila Pa 1976). 2014; 39(22)(Suppl 1): S136-S138.

41. Burwell SM. Setting value-based payment goals—HHS efforts to
improve U.S. health care. N Engl J Med. 2015; 372(10): 897-899.

42. Martin-Misener R, Harbman P, Donald F, et al. Cost-effectiveness
of nurse practitioners in primary and specialised ambulatory care:
systematic review. BMJ Open. 2015; 5(6): e007167.

43. Mullinix C, Bucholtz DP. Role and quality of nurse practitioner prac-
tice: a policy issue. Nurs Outlook. 2009; 57(2): 93-98.

WWW.ANNFAMMED.ORG

https://psnet.ahrq.gov/webmm/case/271/comanagement-whos-in-charge

https://www.nationalahec.org/pdfs/vsrt-team-based-care-principles-values

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.458.383&rep=rep1&type=pdf

Copyright of Annals of Family Medicine is the property of Annals of Family Medicine and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

Journal of Professional Nursing

33 (2017) 400–404

Contents lists available at ScienceDirect

Journal of Professional Nursing

Original Articles

Is health care payment reform impacting nurses’ work settings, roles, and
education preparation?

Mary Val Palumbo a,⁎, Betty Rambur b, Vicki Hart c
a University of Vermont, College of Nursing and Health Sciences, 106 Carrigan Drive, Rowell 216, Burlington, VT 05405, United States
b University of Rhode Island, Routhier Endowed Chair for Practice, College of Nursing, 39 Butterfield Road, Kingston, RI, 02881, United States
c University of Vermont, Office of Health Promotion Research, 1 South Prospect Street, Rm 4428, Burlington, VT 05401, United States

⁎ Corresponding author.
E-mail addresses: mpalumbo@uvm.edu (M.V. Palumb

(B. Rambur), victoria.hart@uvm.edu (V. Hart).

http://dx.doi.org/10.1016/j.profnurs.2016.11.005
8755-7223/

a b s t r a c t

a r t i c l e i n f o

Article history:
Received 11 August 2016
Accepted 28 November 2016

This study explores nurses’ work settings and educational preparation in the five years before passage of the Af-
fordable Care Act (ACA) and five years after ACA passage, with the aim of identifying areas for nurse educators’
attention. The study setting was one small state undergoing rapid transition away from fee-for-service service
and thus provided the ideal laboratory to assess the impact of health reform on the nursing workforce. A second-
ary analysis of data gathered during relicensure compared the nursing workforce at an interval of one decade,
with surveys in 2005 (n = 4075; 65% response rate) and in 2015 (n = 6723; 97% response rate). Findings dem-
onstrated an increase in the proportion of nurses who reported working in ambulatory care and community set-
tings (p = 0.001). However, there was no associated decrease in the proportion of nurses who reported working
in hospitals. Among respondents who reported employment in the ambulatory care/community settings in 2005,
34.3% had a BSN or higher, a proportion that increased to 41.2% in 2015 (p = 0.010); nevertheless, the greatest
proportional increase was among AD prepared nurses (34% to 48%). Although new nursing roles emerging as a
result of health reform offer baccalaureate nurses the opportunity use the full complement of their knowledge
and skills, these data suggest that BS prepared nurses are not fully accessing these opportunities. Implications
for nursing education and further research are detailed.

Keywords:
Ambulatory care
Nursing education
Payment reform

Introduction

Health care reform and the growing momentum in the volume-to-
value transition creates a new environment for nursing practice. Health
reform rooted in “The Triple Aim” of 1) improved patient experiences,
2) improved population health, and 3) cost containment has seeded
the development of new payment models and redesigned care delivery.
Responsibility for population health and overall cost of care broadens
the accountability horizon for organizations. Instead of responsibility
for an episodic encounter that is billed and reimbursed, payment reform
creates incentives to understand the value of care, the longer term im-
pact of clinical decision making on cost of care and patient overall health
and well-being, and population-level costs. Thus, payment reform is an
element of health reform that potentially creates particular opportuni-
ties for new or renewed roles for nurses. In traditional fee-for-service re-
imbursement schemas, for example, many nursing skills (such as care
management and patient education) equate to a “labor cost,” while
medical services are perceived as a “revenue generator.” Payment re-
form dramatically shifts this equation, suggesting the potential for

o), brambur@uri.edu

more nursing employment in non-acute care settings. Yet have nurses’
work settings and roles evolved as well? This preliminary study ex-
plores nurses’ work settings in the time of reform, five years pre-Afford-
able Care Act passage and five years post ACA passage, with the aim of
clarifying potentially fruitful areas for curricular reform and empirical-
ly-based nurse continuing education.

Background and Context

One element of health reform, the Affordable Care Act of 2010 (ACA),
creates a path toward universal health insurance that builds on the
existing U.S. hybrid financing model of governmental payers (Medicare,
Medicaid, Children’s Health Insurance Program, or CHIPS, and TriCare)
and commercial insurance. It requires that all individuals are covered
by one of these means, either via one of the governmental insurances
or commercial insurance. Commercial insurance may be employer-
based or individually purchased. The law also requires each state to ei-
ther create a “Health Insurance Exchange” or to participate in the federal
exchange. The purpose of the exchanges are to enable individuals and
small businesses to compare different health insurance plans in an “ap-
ples to apples” manner because all plans must include the “essential
benefit package”, i.e., services that much be covered. What differs
among the plans is the “actuarial value” of the plans, the amount of

http://crossmark.crossref.org/dialog/?doi=10.1016/j.profnurs.2016.11.005&domain=pdf

http://dx.doi.org/10.1016/j.profnurs.2016.11.005

mailto:mpalumbo@uvm.edu

mailto:brambur@uri.edu

mailto:victoria.hart@uvm.edu

http://dx.doi.org/10.1016/j.profnurs.2016.11.005

http://www.sciencedirect.com/science/journal/

Table 1
Key provisions of U.S. Department of Health and Human Services January 26, 2015
announcement

Timeline of Medicare Value Based Initiative Date

30% of traditional fee-for-service to value based payments By end of 2016
50% of traditional fee-for-service to value based payments By end of 2018
85% of all tradition medicare payment to quality or value By end of 2016
90% of all traditional medicare payment linked to quality or value By end of 2018

401M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

cost sharing in the form of copayment, deductible, and coinsurance.
These are also standardized by what is termed metal levels. For exam-
ple, in a plan with a 60% actuarial value (AV)—a bronze plan—the in-
sured would pay roughly 40% of health costs but have a lower
monthly premium than, for example, a platinum plan, which has an ac-
tuarial value of roughly 90%. The law subsidizes those who meet eligibil-
ity requirements, provided they select a silver plan (AV value of 70%)

In addition to providing such onramps to health insurance, the ACA
creates incentives for testing alternative payment models (APMs) to ad-
dress the limitations created by traditional fee-for-service (FFS) reim-
bursement, a payment model that fragments care by creating
payment silos rather than seamless care across the care continuum.
Fee-for-service also fuels accelerating health care cost, overtreatment
and overutilization while simultaneously leaving others underserved
and undertreated. For ease of understanding, APMs can be bracketed
in two broad categories that create differing provider incentives for
care and thus different delivery models. The first category is a variant
of FFS in which providers are held accountable for the outcomes of
care. In the second category, providers bear responsibility for not only
the outcomes care but also the cost of that care. Examples of the former
include patient centered medical homes, person centered health neigh-
borhoods, and other pay-for-performance models in which providers
receive additional compensation if quality targets are met. Examples
of the latter include most Accountable Care Organizations (ACOs),1 bun-
dled payments, and fixed revenue total cost of care “global budgets”. Ac-
countability for the cost of clinical decision making, termed “risk
bearing,” is new to many providers. In such models, for example, a diag-
nosis, prescription, education and follow-up to treat a new diabetic is
not adequate. Instead, with payment reform there is a financial incen-
tive to assure that the person is managing their diabetes, avoiding hos-
pitalization and emergency room visits, and receiving the most
effective, least expensive care possible. Conversely, fee-for-service
tends to incentivize the most expensive care if the person is well-in-
sured. Thus, payment reform away from fee-for-service creates enor-
mous opportunities for the management of chronic conditions in a
manner that is well aligned with nursing expertise. Medicare’s historic
2015 announcement (see Table 1 for details) has greatly accelerated
the movement from a fee-for service, volume based system to a value
based system; substantial transition was planned for 2016, with a target
of 90% of provider reimbursement linked to quality or outcomes by the
end of 2018. Moreover, while participation in ACOs is voluntary, Medi-
care is requiring bundled payments (one payment for the full episode of
care across the care continuum) for joint replacement in over 600 hos-
pitals within randomly selected health services areas. In August 2016,
two cardiac bundled payments in 98 randomly selected metropolitan
areas were added, and the initial orthopedic bundle settings expanded
to include lower-extreamity joint replacement. Thus, although the
pace at which the payers and providers in various states adopt such al-
ternative payment models differs, Medicare’s adoption is precedent set-
ting. Notably, in traditional FFS, poor quality care receives the same

1 There are three iterations of ACOs, Pioneer, Shared Savings, and Next Generation. Both
Pioneer and Next Generation incorporate provider risk bearing. There are four version of
Next Generation ACOs, one of which maximizes provider risk-sharing in a fixed revenue
model, meaning more services do not equate to more revenue and thereby is the largest
contrast to traditional fee-for-service. Shared Savings ACOs have a risk sharing model in
which providers assume the cost of care beyond what was projected for a given popula-
tion. This is termed “down side risk,” nevertheless, there are “upside only” ACOs in which
providers share in any savings above what was projected for the cost of care for a popula-
tion provided designated quality metrics are met, but none of the cost. The reader is ad-
vised to carefully explore the exact APMs that have been developed and are being
developed and tested in their area, as there is dramatic variability throughout the states
and even within states. The largest provider groups in the study setting have embraced
the Next Generation fixed revenue model and therefore provide a dynamic policy labora-
tory. Since the initial draft of this manuscript the study setting has negotiated an agree-
ment with Medicare that creates the opportunity for an All-Payer statewide ACO (see
http://healthaffairs.org/blog/2016/11/22/the-all-payer-accountable-care-organization-
model-an-opportunity-for-vermont-and-an-exemplar-for-the-nation/).

compensation or even better compensation than high quality care.
Medicare had begun to address such perverse incentives with reim-
bursement policies that preclude reimbursement for same cause read-
mission if it is within one month after discharge and fining hospitals
whose readmission rate is too high, to name just two examples. Similar-
ly, hospital acquired conditions, including those reflecting nurse sensi-
tive indicators such as urinary tract infections, no longer generate
additional reimbursement. These payment changes have created deliv-
ery changes that nurses see regularly in practice. The shift to virtually all
reimbursement being tied to value has the potential to completely rede-
sign the U.S. health care system. Notably, these changes are exterior to
the ACA and rooted in Medicare rules.

The impact of Medicare payment reform cannot be overstated for
two primary reasons: 1) Medicare is the payer of health care for a
large proportion of Americans, a scenario that is growing steadily with
the aging of the Baby Boomer cohort; and 2) Medicaid and commercial
insurance often follow Medicare practices, potentially meaning that the
value-based scenario could represent nearly all of health care reim-
bursement, and reimbursement shapes practice behavior.

Yet what about nursing roles in a reformed system? Workforce re-
searchers Fraher, Ricketts, Lefebvre, and Newton (2013) underscore
the pivotal role of registered nurses, as follows:

Because of sheer numbers—the U.S. health care system employs 2.7
million registered nurses—it is nurses who are arguably in the most piv-
otal position to drive system change. … More attention needs to be
given, first, to identifying the competencies nurses need in these new
roles and, then, to providing continuing professional development op-
portunities for nurses who wish to undertake the new functions (p.
1813).

Educational essentials of baccalaureate and higher degree programs
(AACN, 2006, 2008, 2011) include skills such as care coordination that
are foundational to the emerging payment reform models described
above. Nevertheless, there is scant empirical evidence exploring nurses’
work setting migrations over time. It is also unclear if health care reform
is associated with a change in the composite educational preparation of
nurses outside the acute care setting. This is particularly key in the era in
payment reform, given that associate degree prepared nurses—the larg-
est proportion of the nursing workforce in most regions—typically do
not have course work to prepare them to work in population-focused
settings or in settings outside of traditional acute or long term care.
Thus, this study seeks to clarify if the role and setting shifts portended
by health and payment reform are actually emerging.

Specifically, the current study seeks to explore changes in the nurs-
ing workforce practice settings by education preparation and other de-
mographic factors. One small state undergoing rapid transition away
from fee-for service, Vermont, provides the ideal laboratory to assess
the impact of health reform on nurses’ practice setting and was there-
fore chosen as the study setting. 124 (57%) primary care practices in
the state are “Blueprint Practices.” the state’s term for an intergrated ap-
proach to patient centered medical homes (Department of Vermont
Health Access, 2014; University of Vermont AHEC, 2013). The state
has also passed landmark legislation in 2011 that includes aggressive
movement away from tradition fee-for service. Roughly half the state’s
health services areas were deemed prepared for full risk sharing as the
state prepared for an “all payer” model inclusive of a Medicare waiver
to enable all-inclusive, capitated, reimbursement rather than fee-for-

http://healthaffairs.org/blog/2016/11/22/the-all-payer-accountable-care-organization-model-an-opportunity-for-vermont-and-an-exemplar-for-the-nation/

Table 2
Elements of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) and Ac-
companying Merit Incentive Program (MIPS)

Physician/nurse practitioner fee schedules in fee-for-service—0.5% increase until
2020, then 0%

Reimbursement based on “merit,” determined by metrics inclusive of quality,
resource use, clinical practice improvement activities and meaningful use of
certified electronic health record technology.

Merit score results in range of reimbursement from −4% to +4% in 2019; −5 to
+5 in 2020; −7 to +7 in 2021; and −9 to +9 from 2022 onward.
Providers in qualifying alternative payment models are exempt from MIPs and
receive 5% incentive payment from 2019 through 2024

Source: Centers for Medicare and Medicaid Services (2015). Retrieved from https://
www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-
Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html on August 5,
2016.

Table 3
Demographics.

Demographics 2005 all
n = 4075

2005 a/c
n = 319

2015 all
n = 6723

2015 a/c
n = 668

Gender 94% female 99% female 91% female 94% female
Mean age 48 years 49 years 48 years 49 years
Caucasian 95% 96% 93% 628 (94%)
Other races 2.8% 0.3% 3.5% 19 (3%)
Hispanic (1%) (0%) (4%) 8 (1%)
Missing race data 2.2% 4% 4% 25 (4%)

Position/major activity 2005 all
n = 4075

2005 a/c
n = 319
2015 all
n = 6723
2015 a/c
n = 668

Patient care 2554(63%) 227 (71%) 4697 (70%) 485 (73%)
Consultant n/a n/a 126 (2%) 12 (2%)
Nurse executive 168 (4%) 6 (2%) 194 (3%) 15 (2%)
Nurse faculty/teaching 217 (5%) 15 (5%) 195 (3%) 6 (1%)
Nurse manager 354 (9%) 29 (9%) 738 (11%) 80 (12%)
Other 762(19%) 41 (18%) 754 (11%) 69 (10%)

Education 2005 all
n = 4075

2005 a/c
n = 319
2015 all
n = 6723

2015 a/c
n = 665

Diploma 849 (21%) 92 (29%) 621 (9%) 73 (11%)
ADN 1576 (39%) 109 (34%) 3159 (47%) 315 (48%)
BSN 1321 (32%) 101 (32%) 2505 (37%) 235 (35%)

402 M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

service. National adoption of such APMs is further catalyzed by the 2015
Medicare Access and CHIP Reauthorization Act (MACRA) and accompa-
nying Merit Incentive Program (MIPs-see Table 2 for details on MACRA
and MIPs). This legislation provides a 5% financial incentive for pro-
viders in APMs and excludes them from MIPs, the latter being a complex
set of infrastructure requirements that may still lead to an up to 9% on-
going decrease in revenue by 2022. This Federal initiative, notably
subtitled “Path Toward Value” and outside the ACA, will further the fi-
nancial incentives for reorganization of the US health care system to-
ward value and away from the costly, ineffective care that mars the US
system. Notably, providers—including nurses—have been socialized in
this environment and thus considerable retooling may be required for
contemporary practice. Therefore, regardless of current payment re-
form in a particular state, the experience of Vermont may hold impor-
tant lessons.; practice patterns in the rapidly changing landscape in
Vermont may offer other states a predictive snapshot of nursing work-
force changes in an era of payment reform.

Hypotheses

The hypotheses guiding this study are as follows:
When comparing nursing workforce survey data pre reform (2005)

and post reform (2015) there will be:

1. an increase in the proportion of nurses who report working in ambu-
latory care/community settings/Accountable Care Organizations/pa-
tient centered medical homes

2. a decrease in the proportion of nurses who report working in
hospitals.

3. a decrease in the proportion of associate degree and diploma educat-
ed nurses who report employment in ambulatory care/community
settings.

4. an increase in the proportion of nurses educated at the baccalaureate
or higher degree level who report employment in ambulatory care/
community settings.

MSN 187 (5%) 3 (1%) 382 (6%) 39 (6%)
Doctorate 6(b1%) 3 (1%) 30 (0.4%) 4 (0.6%)
Missing 131 (3%) 12 (4%)

Aggregate of BS or higher 2005 all
n = 4075

2005 a/c
n = 319
2015 all
n = 6723
2015 a/c
n = 665

BS or higher in nursing (37%) (33%) (44%) (42%)
BS – other 547 (13%) 20 (6%) 824 (12%) 86 (13%)
MS – other 214 (5%) 38 (12%) 360 (5%) 31 (5%)
Doctorate (nursing or
non-nsg)

6 (0.15%) 0 (0%) (17) 0.25%
(DNP)

1 (0.1%)

18 (0.44%) (13) 0.19%
(PhD)

Currently enrolled in a
nursing program

233 (6%) 15 (5%) 596 (9%) 38 (6%)

Legend: all = all respondents; a/c refers to respondents who reported ambulatory or com-
munity settings.

Methods

This is a comparative study using secondary analysis design to ex-
amine the nursing workforce at an interval of one decade, 2005 (n =
4075; 65% response rate) and 2015 (n = 6723; 97% response rate).
These data are gathered at the time of Registered Nurse licensure re-
newal and reflect the Nursing Workforce Minimum Data Set (Cleary &
Rice, 2005). There was a slight difference in the data collection strategy
over the course of the decade, based on changes in the state’s re-licen-
sure protocol. The survey was a voluntary paper survey in 2005, and
was legislatively mandated for inclusion in the 2015 relicensure pro-
cess. In 2015, the default data collection mechanism was electronic,
with a paper survey available upon request. Data were reviewed to

identify nurses who reported practicing in sites listed under the catego-
ry of ambulatory care and community health.

Statistical analysis: Descriptive statistics were used to characterize
the study population. Chi-square tests of comparison were performed
to evaluate the study hypotheses. Results were considered significant
at a 95% level of confidence (p ≤ 0.05).

Findings

Hypothesis 1 was supported

There was an increase in the proportion of nurses who report work-
ing in ambulatory care/community settings/Accountable Care Organiza-
tions/patient centered medical homes. In 2005, 8.0% of respondents
worked in Ambulatory Care/Community Health settings. This compares
to 10.0% in 2015 (Table 3). This represents a significant increase from
2005 to 2015 (χ2 = 11.5, p b 0.01).

Hypothesis 2 was not supported

There was no decrease in the proportion of nurses who report work-
ing in hospitals. Instead, there was a slight increase, which bordered on
statistical significance. In 2005, 50.0% of respondents worked in a hospi-
tal setting. This compares to 51.9% in 2015 (Table 3). This represents a
borderline significant increase from 2005 to 2015 (χ2 = 4.7, p = 0.05).

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

403M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

Hypothesis 3 was not fully supported

There was a decrease in diploma educated nurses from 2005 (29%)
to 2015 (11%) (χ2 = 50.7, p b 0.01); but there was a substantial increase
in the proportion of AD prepared nurses, from 34% to 48% (χ2 = 11.7,
p b 0.01) (Table 3).

Hypothesis 4 was supported

Among respondents who reported employment in the Ambulatory
Care/Community Health setting in 2005, 34.3% had a BSN or higher.
This compares to 41.2% in 2015). This represents a significant increase
from 2005 to 2015 (χ2 = 9.3, p = 0.01)

Subject demographics and reported position are described in Table
3. Additional post hoc analysis of the 2005 and 2015 data revealed the
positions for nurses who reported working in the ambulatory/commu-
nity settings (see Table 4).

Discussion

These data suggest that a shift to ambulatory and community based
settings is indeed occurring for nurses at all levels of education except
the diploma-prepared (who are aging out of the workforce); however,
a shift away from hospital employment was not identified. The settings
in which nurses are employed is important for many reasons. The N-
CLEX exam, for example, serves as the gateway to nursing practice
and tests for competency in common practice settings. Historically,
the N-CLEX exam has been primarily acute-care oriented and reflected
the competencies perceived to be needed for new graduates. Very dif-
ferent skill sets are needed in a reformed health system; for example,
the use of predictive analytics for individual and population health man-
agement. Yet, will competency in these areas be considered a “safe prac-
tice” issue and then accordingly be manifest in N-CLEX assessment of
essential competencies? The rapid change in payment models portends
an equally rapid shift in what constitutes safe and effective practice;
therefore, immediate attention to the gatekeeping exam is warranted.
Arguably, this will also subtly further shape nursing education. Al-
though curricula are explicitly referenced to guidelines such as AACN’s
Essentials of Baccalaureate Education, in the authors’ experience with
nurse educators around the nation, the N-CLEX pass rate was an impor-
tant implicit factor in curricular emphasis and also one by which pro-
grams compare themselves to others, particularly in states where the
associate degree pass rate is higher than the baccalaureate. No empirical
evidence could be found to support or refute this statement and it re-
mains an important, unanswered research question.

The increase in nurses who have obtained the bachelor’s degree in
nursing or higher in the ambulatory care setting is encouraging, as is
the more than doubling of in the actual number of ambulatory care
nurses who are currently enrolled in an educational program (15 in
2005 and 38 in 2015). Nurses may be recognizing that the skills needed
for population health and transitional care are available through con-
tinuing their nursing education. Nevertheless, the overall proportion
of nurses who are continuing their education is dismally low, a particu-
lar concern given the large proportion of AD nurses working in this set-
ting. A larger concern is the substantial increase in the proportion of
associate degree nurses employed in ambulatory care. Traditional

Table 4
Workplace settings.

Setting 2005 n (%) 2015 n (%)

Ambulatory/community health 318 (8.0%) 667 (10.0%)
Hospital 1986 (50.0%) 3482 (51.9%)
Other 1677 (42.0%) 2556 (38.0%
Missing 1 (b0.1%) 19 (0.1%)
Total 3982 (100%) 6724 (100%)

associate degree education has been acute and long term care centric,
with less focus on community and population health. Nevertheless,
these data suggest that employers are disproportionately employing
these individuals, suggesting that either baccalaureate prepared nurses
have not yet been seen as value-added or they are not available for these
positons. Additionally, Bevill, Cleary, Lacey, and Nooney (2007) sug-
gested that as more nurses achieve a bachelor’s degree, there is a better
chance that they will further continue their education and be ready to
fill needed roles as nurse educators or nurse practitioners. At the same
time, it is unclear if baccalaureate prepared nurses are optimizing
their potential to utilize a full array of skills and knowledge to support
highly functioning emerging models of care.

This study did not find a decrease in the proportion of nurses
employed in hospitals. There are a number of potential explanations
for this. The ACA has spurred mergers of organizations and a move to-
ward integration. The use of secondary data in this study did not enable
more nuanced analyses of work role and setting. It is possible that
nurses perceive their setting as “hospital” even if they are involved in
“same day” options or part of a hospital based Accountable Care Organi-
zation, the most common APM in the study setting. Similarly, a transi-
tional care nurse working in a congestive health failure demonstration
project in the state whose nominal employer is a hospital may not per-
ceive themselves as involved in an APM but instead “hospital
employed.” Another possibility is that there is no nursing employment
shift away from hospital settings, or that the value based movement is
just too early in its trajectory to manifest such shifts. Yet another consid-
eration is that the ACA enabled previously unensured individuals to ac-
cess the system, and there was pent up demand for acute care services
among these individuals. Finally, the use of the Minimum Data Set,
while offering important consistency and potential for comparisons, is
not highly nuanced and may not be sufficiently sensitive. Further stud-
ies exploring work roles in detail would be an important complement to
this preliminary study

Additional questions are raised by the study: does payment reform
create new roles for nurses or just renewed roles? The California
Institute for Nursing and Health Care (2013) has detailed nursing roles
that have emerged as a result of health reform. These include care coor-
dinators inclusive of population health management and tiered coordi-
nation, “nurse/family cooperative facilitator” and “primary care
partner”. These roles have been further explicated in the 2016 Macy
Foundation Conference Recommendations, Registered Nurses: Partners
in Transforming Primary Care. As previously noted, traditional workforce
data, including the standard Minimum Data Set, may not be sufficiently
nuanced to capture and thus reflect such roles and, paradoxically, fur-
ther cloud workforce analyses. This may be particularly pronounced
when the nurse works across the care continuum in a post fee-for-ser-
vice delivery model such as those grounded in bundled payments or
global budgets. Nevertheless, these role have the potential to offer sig-
nificant value to society and support The Triple Aim. Indeed, as early
as 2001, 15 years of evidence defined the attributes of the nurse case
manager (Reimanis, Cohen, & Redman, 2001). Attention has also been
given to the need for nurses to be prepare to transition from caregiver
to case manager (Schmitt, 2005). For nurses to play a leadership role
in the evolution of the health care system, enhanced experience in man-
aging patient populations is necessary, as these roles will likely become
more prevalent. The prerequisite skill set includes the ability to facilitate
interprofessional care teams and track patient populations to imple-
ment evidence based interventions, then track outcomes as well as
the cost.

Nursing faculty control nursing education. Clear delineation of the
differences between public health and population health are needed,
as well as explication of overlapping skill sets. Reconsideration of curric-
ular design is also warranted, as the packaging of courses signals to stu-
dents what faculty perceive as important and socializes them within
that model. Courses that reflect hospital units (i.e. “Med/Surg”), regard-
less of the actual title of the course, are outmoded and inadequate for

404 M.V. Palumbo et al. / Journal of Professional Nursing 33 (2017) 400–404

the changes heralded by payment reform. Similarly, lifespan courses,
such “nursing care of children” need contemporary conceptualizations
that reflect trends such as “housing as health care” (Doran, Misa, &
Shah, 2013) and the use of resources to prevent hospitalization. An ex-
ample of the latter would be navigating the social and reimbursement
landscape to provide an air conditioner to a poor family whose child
has had frequent emergency department visits secondary to particulate
induced asthma. These sort of nursing interventions are incentivized in
any system in which providers bear risk for the cost of care. Moreover,
nurses’ holistic orientation that moves well beyond the limitations of
the medical model is well suited to these opportunities and responsibil-
ities. Clarity on skills expected at the associate degree level and bacca-
laureate level as well as role definition is essential. The nurses of this
nation will not be prepared for the role shifts accompanying payment
reform if both such program types continue to be disproportionally fo-
cused on acute care skills, or acute care with the one semester of “com-
munity” or public health.

Recommendations for Further Research

Clarity on nurses’ work role, as well as employer’s perceptions of
gaps in workforce skills in the array of payment models would offer im-
portant information to nursing education and regulation, including N-
CLEX development. Jones-Bell et al. (2014) for example, note that health
outcomes for primary, ambulatory, and community health care prac-
tices utilizing registered nurses practicing to the fullest extent of their
education in the role of care coordinators is important to support cost
effectiveness in these critical settings. Yet, care coordination is only
one aspect of essential nursing knowledge. Expertise in care redesign
to maximize outcomes while reducing cost are prized skills in a nation
that currently spends more on health care than any other country, yet
has outcomes that consistently lag behind other nations (Squires,
2011).

Team based care is currently a predominate focus in both nursing
education and continuing education, yet team based care is a strategy
toward the Triple Aim, not an outcome in and of itself. It is currently un-
clear how the work role of a nurse in a particular setting intersects with
other team members. Also unclear is if the role of “nurse manager” in
outpatient settings includes care management that includes other
team members or is limited to managing nursing staff in a particular set-
ting. Further workforce research is needed to uncover the changes in the
work of the nurse manager in the ambulatory care setting.

Value-based payment that is not rooted in fee-for-service educes the
use of teams working to the full extent of their knowledge and license
because revenue is not driven by physician care or hospitalization. In-
deed, in full risk bearing models, all services are a cost. Therefore, essen-
tial nursing knowledge in ambulatory care settings will include
understanding payment models and the metrics on which organiza-
tions are measured as a basis for payment.

Limitations

This study’s setting was one U.S. state, which limits nationwide gen-
eralizability. Nevertheless, the implications may transfer to other U.S.
states in a rapid volume to value shift. The 2005 response rate, while ro-
bust at 65%, is not as substantial as the 97% in 2015, and it is impossible
to know if the non-responders differ from the responders in a manner

that would impact the conclusion. Finally, the limitations of the Nursing
Minimum Data set are evident, as it is impossible to discern to complex-
ity of the nursing role or if it is in a traditional or reimagined role in a
redesigned system of care. Terms such as “ambulatory care” are not re-
flective of the complexity and array of relevant workforce settings. Fu-
ture research to address these limitations, including the potential
development of an instrument that is sensitive to nuanced workforce
changes, would create a valuable contribution to society.

Acknowledgments

Vermont AHEC Nursing Initiatives.
AARP/RWJF Future of Nursing State Implementation Program grant

(#731Q9).

References

AACN (2006). The essentials of doctoral education for advanced nursing practice. Re-
trieved from http://www.aacn.nche.edu/dnp/Essentials .

AACN (2008). The essentials of baccalaureate education for professional nursing practice.
http://www.aacn.nche.edu/education-resources/BaccEssentials08 Retrieved from
http://www.aacn.nche.edu/education-resources/BaccEssentials08 .

AACN (2011). The essentials of master’s education in nursing. Retrieved from http://
www.aacn.nche.edu/education-resources/MastersEssentials11 .

Bevill, J. W., Jr., Cleary, B. L., Lacey, L. M., & Nooney, J. G. (2007). Educational mobility of
RNs in North Carolina: Who will teach tomorrow’s nurses? A report on the first
study to longitudinally examine educational mobility among nurses. The American
Journal of Nursing, 107(5), 60–70 quiz 71 http://dx.doi.org/10.1097/01.naj.
0000268172.71477.99.

California Institute for Nursing and Health Care (2013). Nurse role exploration project:
The affordable care act and new nursing roles. http://www.calhospital.org/sites/
main/files/file-attachments/cinhc_whitepapernurseroles Retrieved from http://
www.calhospital.org/sites/main/files/file-attachments/cinhc_whitepapernurseroles.
pdf.

Centers for Medicare and Medicaid Services (2015). Retrieved from https://www.cms.
gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-
Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

Cleary, B., & Rice, R. (Eds.). (2005). Nursing workforce development strategic state initiatives.
New York, NY: Springer Publishing Company.

Department of Vermont Health Access (2014). Vermont blueprint for health 2014 annual
report. Retrieved from http://legislature.vermont.gov/assets/Legislative-Reports/
VTBlueprintforHealthAnnualReport2014-Final.2015.01.26 .

Doran, K., Misa, E., & Shah, N. (2013). Housing as health care—New York’s boundary-
crossing experiment. New England Journal of Medicine, 369, 2374–2377. http://dx.
doi.org/10.1056/NEJMp1310121.

Fraher, E. P., Ricketts, T. C., Lefebvre, A., & Newton, W. P. (2013). The role of academic
health centers and their partners in reconfiguring and retooling the existing work-
force to practice in a transformed health system. Academic Medicine, 88(12),
1812–1816. http://dx.doi.org/10.1097/acm.0000000000000024.

Jones-Bell, J., Karshmer, J., Berman, A., Prion, S., Van, P., Wallace, J., & West, N. (2014). Col-
laborative academic-practice transition program for new graduate RNs in community
settings: Lessons learned. Journal of Continuing Education in Nursing, 45(6), 259–264.
http://dx.doi.org/10.3928/00220124-20140402-01.

Macy Foundation (2016). Registered Nurses: Partners in Transforming Primary Care. Con-
ference Proceedings available at http://macyfoundation.org/docs/macy_pubs/201609_
Nursing_Conference_Exectuive_Summary_Final

Reimanis, C. L., Cohen, E. L., & Redman, R. (2001). Nurse case manager role attributes: Fif-
teen years of evidence-based literature. Lippincott’s Case Management, 6(6), 230–239
(quiz 240–232).

Schmitt, N. (2005). Role transition from caregiver to case manager, part 1. Lippincott’s
Case Management, 10(6), 294–302.

Squires, D. (2011). The U.S. health system in perspective: A comparison of twelve indus-
trialized nations. Retrieved from http://www.commonwealthfund.org/~/media/
Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_
nations_intl_brief_v2 .

University of Vermont AHEC (2013). Vermont primary care workforce 2013
snapshot. Retrieved from http://www.uvm.edu/medicine/ahec/documents/
AHEC2013PCReport2014_01_28_001 .

http://www.aacn.nche.edu/dnp/Essentials

http://www.aacn.nche.edu/education-resources/BaccEssentials08

http://www.aacn.nche.edu/education-resources/MastersEssentials11

http://dx.doi.org/

http://www.calhospital.org/sites/main/files/file-attachments/cinhc_whitepapernurseroles

http://https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

http://refhub.elsevier.com/S8755-7223(16)30113-2/rf0030

http://legislature.vermont.gov/assets/Legislative-Reports/VTBlueprintforHealthAnnualReport2014-Final.2015.01.26

http://dx.doi.org/10.1056/NEJMp1310121

http://dx.doi.org/10.1097/acm.0000000000000024

http://dx.doi.org/10.3928/00220124-20140402-01

http://macyfoundation.org/docs/macy_pubs/201609_Nursing_Conference_Exectuive_Summary_Final

http://refhub.elsevier.com/S8755-7223(16)30113-2/rf0055

http://refhub.elsevier.com/S8755-7223(16)30113-2/rf0060

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jul/1532_Squires_US_hlt_sys_comparison_12_nations_intl_brief_v2

http://www.uvm.edu/medicine/ahec/documents/AHEC2013PCReport2014_01_28_001

Is health care payment reform impacting nurses’ work settings, roles, and education preparation?

Introduction
Background and Context
Hypotheses
Methods
Findings
Hypothesis 1 was supported
Hypothesis 2 was not supported
Hypothesis 3 was not fully supported
Hypothesis 4 was supported
Discussion
Recommendations for Further Research
Limitations
Acknowledgments
References

SPECIAL COMMUNICATION

How Evolving United States Payment Model

Influence Primary Care and Its Impact on th

Quadruple Aim
Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew Bazemore, MD, MPH,
and Winston Liaw, MD, MPH

Introduction: Prior research has demonstrated the associations between a strong primary care founda-
tion with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the
United States reinforces the volume of services over value-based care, thereby devaluing primary care,
and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from
volume-based to value-based payment models, the Medicare Access and Children’s Health Insurance
Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a
taxonomy of the major health care payment models, reviewing their ability to uphold the functions of
primary care, and their impacts across the Quadruple Aim

Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for
America’s Health payment and research tactic teams were used. Titles and abstracts were reviewed for
relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely an

relevant articles.

Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a
limited evidence base. Several cross-cutting lessons from available payment models several recommen-
dations for primary care payment models, including the following: implementing per member per
month– based models, validating risk-adjustment tools, increasing investments in integrated behavioral
health and social services, and connecting payments to patient-oriented and primary care-oriented met-
rics. Along with ongoing research in emerging payment models, data systems integrated across health
care and social services settings using metrics that can capture the ideal functions of primary care will
be critical to the development of future payment models that most optimally enhance the role of pri-
mary care in the United States.

Conclusions: Although the ideal payment model for primary care remains to be determined, lessons
learned from existing payment models can help guide the shift from volume-based to value-based care.
To most effectively pay for primary care, future payment models should invest in a primary care infra-
structure, one that supports team-based, community-oriented care, and measures the delivery of the
functions of primary care. ( J Am Board Fam Med 2018;31:588 – 604.

)

Keywords: Delivery of Health Care, Family Medicine, Health Expenditures, Primary Health Ca

Forty years ago, in the milestone “Declaration of
Alma Ata,” all member nations of the World
Health Organization declared that achieving health
for all was dependent on a foundation of primary

care.1 A quarter century later, Dr. Barbara Starfield
added to the evidence base, demonstrating tha

primary care produces higher quality of care, im-

This article was externally peer reviewed.
Submitted 26 September 2017; revised 11 March 2018;

accepted 13 March 2018.
From the Department of Family Medicine, Oreg

Health & Science University, Portland, OR (BP); Eugene S.
Farley, Jr. Health Policy Center, University of Colorado
School of Medicine, Denver, CO (SBG); Robert Graham

Center for Policy Studies in Family Medicine and Primary
Care, Washington, D.C. (AB, WL).

Funding: none.
Conflict of interest: none declared.
Corresponding author: Brian Park, MD MPH, Department

of Family Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Pk Rd, Mailcode FM, Portland, OR
97239 �E-mail: parbr@ohsu.edu).

588 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

o
n

2
3

F
e

b
ru

a
ry 2

0
2

0
b

y g
u
e

st.

P
ro

te
cte

d
b

y co
p

yrig
h

t.
h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

8
.0

4
.1

7
0
3
8
8
o

n
9

Ju
ly 2

0
1
8
. D

o
w

n
lo

a
d
e
d
fro

http://www.jabfm.org/

proves health outcomes, increases access, lowers
costs, and attenuates disparities.2,3,4 She attribut

the positive impact of primary care on health sys-
tems to the “4 Cs,” which define its function: first
contact, continuity, comprehensiveness, and coor-
dination (Figure 1).4 Subsequent research has dem-
onstrated that supporting these 4 Cs are the ele-
ments of primary care that help health systems
achieve the Quadruple Aim of improving patients’
experience of care, population health, and physi-
cian satisfaction, while reducing costs.5,6,7,8

Starfield’s work and the healthcare system’s
longstanding inattention to primary care may ex-
plain the ongoing failure of the United States to
achieve its Quadruple Aims, given the inadequate
system level support for primary care.9,10,11,12,13,14

Its predominant fee-for-service (FFS) payment
model has long been thought to undermine or
insufficiently support the 4 Cs that explain primary
care’s positive effects.15,16,17 Under pure FFS pay-
ment models, clinicians are reimbursed retroac-
tively for services, incentivizing higher volume,
treatment rather than prevention, and fragmenta-
tion of care without regard for quality or cost. Such
models reward greater numbers of services ren-
dered (ie, volume) rather than the quality and cost
of care provided to patients (ie, value).18,19

Payers, public and private, are experimenting
with shifting from paying for volume to paying for

value. The Affordable Care Act included provisions
that advance primary care and value-based pay-
ment, including the creation of the Center for
Medicare and Medicaid Innovation (CMMI), which
has tested innovative payment and delivery system
models aimed at improving value.20,21,22 Five years
after the Affordable Care Act, the Medicare Acce

and Children’s Health Insurance Program CHIP Re-
authorization Act (MACRA) passed. Under MACRA,
providers1 will select 1 of 2 incentive tracks: the al-
ternative payment model (APM; see Table 1) or the
Merit-Based Incentive Payment System (see Table
2).23 Both programs provide incentives for improving
quality and reducing costs.

As value-based payment spreads, better under-
standing of existing models can guide which ap-
proaches deserve ongoing implementation and re-
search efforts. This narrative review of the literature
proposes a taxonomy of the major health care pay-
ment models, highlights their distinguishing charac-
teristics (Table 3), and reviews their impacts across
the Quadruple Aim (Table 4). We also discuss the
impact of each payment model in supporting the 4
Cs of primary care; given the lack of widespread use
and standardized metrics in measuring these pri-

1Eligible clinicians provide care for at least 100 Medicare
patients and bill for greater than $30,000 of Medicare Part B
services.

Table 1. Scheduled Adjustments in APM Eligibility Criteria under Medicare Access and Children’s Health
Insurance Program Reauthorization Act

Year Eligibility

2019 and 2020 �25% of total Medicare revenue is from a qualified, eligible APM
2021 and 2022 �50% of total Medicare revenue OR

�25% of total Medicare revenue and 50% of all-payer revenue (eg, Medicaid, private insurer

is from a qualified, eligible APM

2023 and beyond �75% of total Medicare revenue OR
�25% of total Medicare revenue and 75% of all-payer revenue is from a qualified, eligible APM

APM, alternative payment model; OR, odd ratio.

Figure 1. The 4 Cs of Primary Care.

• Contact: Accessibility as the first contact with the health care system
• Comprehensiveness: Accountability for addressing a vast majority of personal health

care needs,
• Coordination: Coordination of care across settings, and integration of care for acute

and (often comorbid) chronic illnesses, mental health, and prevention, guiding access
to more narrowly focused care when needed,

• Continuity: Sustained partnership and personal relationships over time with patients
known in the context of family and community.

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 589

o
n
2
3
F
e
b
ru
a
ry 2
0
2
0
b
y g
u
e

st. P
ro

te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w
w
.ja
b
fm
.o
rg
/
J A

m
B

o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9
Ju
ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m

http://www.jabfm.org/

mary care attributes24, when relevant, we consider
the hypothetical impacts of each model when for-
mal metrics were not used. Based on these findings,
we provide policy and research recommendations
for payment reform to best advance primary care.

Methods
Starfield Summit I: Advancing Primary Care
Research, Policy, and Patient Care
The first iteration of this narrative review was con-
ducted before the inaugural Starfield Summit
(http://www.starfieldsummit.com) on April 24 to
26, 2016, in Washington, D.C. It was intended to
inform and capture informant input from the Sum-
mit’s nearly 150 invited primary care leaders
(PCPs), researchers, and health care leaders to dis-
cuss and enable research and policy agenda-setting
around primary care payment, measurement, and
teams.25

Literature Review
We first conducted a literature search26 on primary
care payment, enriched through expert consulta-
tion before, during, and after the Summit. In
March 2016, an Ovid MEDLINE search was con-
ducted using the search terms “payment” and “pri-
mary care.” The search was limited to articles pub-
lished in English since 2010, yielding a total of 391
results2, with 97 articles ultimately included in the
review. Exclusion criteria included the following:
inclusion in a subsequent systematic review, up-
dated evidence available (ie, more recent article
from the same demonstration), not focused on pay-
ment models, not focused on Quadruple Aim
and/or the 4 Cs, and non-US evaluations that were
subnational. Additional articles and gray literature
were identified from the expert opinions of mem-
bers of the Family Medicine for America’s Health
payment and research tactic teams and a “snowball”

method of reviewing the references of the search
results. The literature was summarized for each
model, and key demonstrations or projects were
selected, with agreement from at least 2 authors
from the writing group, to highlight examples.

Results
Fee-For-Service
Under FFS, a provider is retrospectively paid a
predefined amount for each service. Consequently,
providers are incentivized to increase volume with-
out bearing financial risk for quality or costs; in-
surers bear high financial risk in this arrangement.
In 1992, the Centers for Medicare and Medicaid
Services (CMS) began using the Resource-Based
Relative Value Scale to set a fee schedule for dif-
ferent services, which has been criticized for dis-
proportionately weighing specialist care and proce-
dures over primary care.27,28 Despite concerns over
the limitations of FFS, its inclusion in a payment
model may enhance the use of services that are
low-cost and underutilized29, such as vaccines in
low immunization areas, where increased volume is
desirable for population health.

Traditional (Or Full-Risk) Capitation
In response to rising costs from FFS, health main-
tenance organizations (HMOs)3 emerged in the
1980s to coordinate care and reduce use30 by capi-
tating payments.26 In traditional capitation, provid-
ers are paid a prospective amount to cover all ser-
vices within a specific period of time, most often as
a per member per month (PMPM) fee. Payments
vary by age-group and sex and are determined
based on prior average costs of care under FFS.31,32

A capitated fee can cover all primary care services,
all outpatient services, or all health care services,

2In the case that a more recent report on a demonstration
project was published between the time of the initial litera-
ture search and submission of this manuscript, we replaced
the prior report with the most up-to-date evidence.

3HMOs and other managed care models also include
other mechanisms for cost control (e.g., narrow provider
networks and pre-authorization of services). For the pur-
poses of this paper, we have examined this model as a
surrogate for capitated payment, though we acknowledge
other mechanisms were in place to contribute to outcomes.

Table 2. Scheduled Payment Adjustments in Merit-Based Incentive Payment System

Adjustment 2019 2020 2021 2022 and beyond

Baseline payment adjustment �4% �5% �7% �9%
Maximum payment adjustment for high performers �12% �15% �21% �27%

590 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

o
n
2
3
F
e
b
ru
a
ry 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w
w
.ja
b
fm
.o
rg
/
J A
m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9
Ju
ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m

http://www.starfieldsummit.com

http://www.jabfm.org/

Ta
bl

e
3.

rv
ie

w
of

Pr
im

ar
y

Ca
re

Pa
ym

en
t

M
od

D
es

cr
ip

ti
on

P
ro

sp
e

ti
ve

s
re

tr
os

pe
ct

iv
e

F
in

an
ci

al
ly

di
sc

ou
ra

ge
s

vo
lu

m
e

of
se

rv
ic

F
in
an
ci
al
ly

en
co

ur
ag

es
hi

gh
qu

al
it

y
of

ca
re

P
ar

ty
th

t
pr

m
ar

ily
be

ar
s

th
e

fi
na

nc
ia

l
ri

sk
?

R
is

k
ad

ju
st

s
fo

r
pa

ti
en

t
co

m
pl

ex
it

y?
K

ey
E

xa
m

pl
e

F
ee

-f
or

-s
er

vi
ce

(

F
F

ai
d

fo
r

ea
ch

in
di

vi
du

l
se

rv
ic

e
re

nd
er

ed
R

et
ro

sp
ec

ti
ve

N
o

n
su

re
rs

N
o

M
ed

ic
ar

e
P

at
ie

nt
s

(v
ia

co
st

-s
ha

ri
ng

:
co

–
pa

ys
,

de
du

ct
ib

le
s)

T
ra

di
ti

on
al

ca
pi

ta
ti

on
(f

ul
l-

ri
sk

ca
pi
ta
ti

on
,

gl
ob

al
pa

m
en

P
ai

d
to

co
ve

r
al

l
se
rv
ic

es
w

t
hi

n
a

sp
ec

ifi
c

pe
ri

od
of

ti
m

e
P
ro
sp
ec
ti
ve

Y
es

N
o,

ex
ce

pt
fo

r
ou

tc
om

es
re

la
te

d
to

us
e

P
ri

m
ar

y
ca

e
pr

ac
ti

ce
s

N
o
M
ed
ic
ar

e
A

dv
an

ta
ge

H
M

O
s

P
ay

-f
or

-p
er

fo
rm

an
ce

(

P
4P

)
ex

is
ts

in
ad

di
ti

on
to

un
de

rl
yi

g
m

od
el

(g
en

er
al

ly
F

F
S

or
ca

pi
ta

ti
on
)
P
ai

d
fo

r
ac

hi
ev

em
en

t
of

(o
r

im
pr

ov
em

en
t

in
)

a
qu

al
it

y
m

ea
su

B
ot

h
ex

is
t

(m
os

t
m

od
el
s
re
tr
os
pe
ct

iv
el

y;
ho

w
ev

er
,

ca
n

be
pa

d
pr

os
pe

ct
iv

el
y

an
d

su
bs

eq
ue

nt
ly

re
co

nc
ile

P
ot

en
ti

al
ly

(d
ep

en
ds

n
qu

al
it
y
m

et
ri

cs
)

Y
es

,
fo

r
se

rv
ic

es
be

in
g

m
ea

su
re

d
vi

a
qu
al
it
y
m
et
ri
c

D
ep

en
ds

on
un

de
rl

yi
ng

pa
ym

en
t

m
od

el
P
ot
en
ti
al
ly
M
ed
ic
ar
e
P

hy
si

ci
an

G
ro

up
P

ra
ct

ic
e

D
em

on
st

ra
ti

on
P

ro
je

t
P

ri
m

ar
y
ca
re

pr
ac

ti
ce

s,
if

ta
rg

et
s

no
t

m
et

B
un

dl
ed

pa
ym
en
t

(e
pi

so
de

–
of

-c
ar

ai
d
fo
r

al
l

se
rv

ic
es

re
nd

er
ed

fo
r

a
gi

ve
n

ep
is

od
e

of
ca

M
ix

ed
(g

en
er

al
ly

re
tr

os
pe
ct
iv
el
y

tr
ig

ge
re

d
an

d
pr
os
pe
ct
iv
el
y

pa
id

)
Y
es

(b
ut

do
es

no
t
di
sc
ou
ra

ge
vo

lu
m

e
of

ep
is

od
es

)
N
o,
ex
ce
pt
fo
r
ou
tc
om
es
re
la
te
d
to

ut
ili

za
ti

on
P
ri
m
ar
y
ca
re
pr
ac
ti

ce
s,

or
ga

ni
za

ti
on
s
N
o

C
M

M
I’

s
B

un
dl

ed
P

ay
m

en
ts

fo
r

C
ar

e
Im

pr
ov

em
en
t

Sh
ar

ed
sa

vi
ng

s
P

ai
d

ba
se

d
on

sp
en

di
ng

be
lo

w
a

pr
ed

et
er

m
in

ed
be

nc
hm

ar
k

ov
er

a
pe

ri
od

of
ti

m
e

(c
on

ti
ng

en
t

on
m

ee
ti

ng
ce

rt
ai

n
qu
al
it

y
ta

rg
et

s)
M
ix

ed
(p

ro
sp

ec
ti

ve
at

le
ve

l
of

th
e

A
C

O
,

bu
t

pr
ov

id
er

s
of

te
n

st
ill

pa
id

vi
a

F
F
S)
Y
es
Y
es
A
C
O
s
P
ot
en
ti
al
ly
M
ed
ic
ar

e
Sh

ar
ed

Sa
vi

ng
s

P
ro

gr
am

A
C
O
s

B
le

nd
ed

F
F

S
an

d
ca

pi
ta
ti
on
P
ai

d
a

pr
ed
et
er
m
in

d
am

ou
nt

in
te

nd
ed

to
co

ve
r

m
ed

ic
al

ho
m

e
se

rv
ic

es
fo

r
a

sp
ec
ifi
c
pe
ri
od
of
ti
m

e
in

ad
di

ti
on

to
F

F
S
M
ix

ed
N

o
(t

o
th

e
ex

te
nt

th
at

F
F

S
is

th
e
pr
ed

om
in

an
t

pa
ym
en
t

m
ec

ha
ni

sm
)

N
o
D
ep
en
ds
on
un
de
rl
yi
ng
pa
ym
en
t
m
od
el
P
ot
en
ti
al
ly
M
ed
ic
ar

e
C

om
pr

eh
en

si
ve

P
ri
m
ar

y
C

ar
e

In
it

ia
ti

C
om

pr
eh

en
si

ve
(p

ri
m

ar
y)

ca
re
pa
ym
en
t
P
ai
d
a
ri
sk

-a
dj

us
te

d
am
ou
nt
to
co
ve
r
al
l

pr
im

ar
y
ca
re
se
rv
ic
es
fo
r

a
sp

ec
ifi

c
pe

ri
od
of
ti

m
e;

in
cl

ud
es

co
m

po
ne

nt
of

P
4P
P
ro
sp
ec
ti
ve
Y
es
Y
es
P
ri
m
ar
y
ca
re
pr
ac
ti
ce
s
Y
es

Io
ra

H
ea

lt
h

C
on

ti
nu

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 591

http://www.jabfm.org/

including inpatient and outpatient. In contrast to
FFS, capitation incentivizes cost control. Capita-
tion may also exist as part of blended models with
mixed PMPM payments and FFS, or in a further
risk-adjusted form mixed with pay-for-perfor-
mance in comprehensive primary care payment;
these models are discussed in a later section. In
contrast to FFS, capitation shifts financial risk to
the provider, while the payer has lower risk.

One study examined the impact of capitation on
one of the 4 Cs and finding capitated models was
associated with decreased first contact (access).33

This may reflect the incentive for providers to
avoid sicker patients (termed adverse selection or
“cherry-picking”) to reduce costs. Another possible
negative impact on the 4 Cs is a financial incentive
to inappropriately underdeliver services, leading to
decreased comprehensiveness.34 The prospective
element of capitation could benefit primary care by
enabling upfront investments in practice compo-
nents that enhance the 4 Cs (eg, care coordination)
and providing flexibility for practices to determine
how finances are spent.

Traditional capitation has demonstrated mixed
effects on cost and quality35,36,37, although most
evidence suggests a decreased use of hospitals and
other expensive resources and worse patient satis-
faction, consistent with the backlash toward HMOs
in the 1990s.38

Pay-For-Performance (P4P)
P4P supplements an underlying payment model,
most often as a bonus on top of FFS. P4P refers to
payment based on the achievement of a quality
target (eg, hemoglobin A1c [HbA1c] level �8 for
diabetic patients or delivery of cancer screening) or
improvement in performance (eg, change from
baseline for HbA1c); the latter approach may at-
tenuate variation in quality across providers, and
provide incentives for both high-performing and
low-performing practices.39

Limited evidence exists for the impact of P4P on
the 4 Cs. The United Kingdom’s Quality and Out-
comes Framework (QOF) found decreased conti-
nuity rates and no differences in patient-reported
perception of coordination, when compared with
preintervention periods.40 Incentivized metrics
tended to improve, whereas nonincentivized met-
rics demonstrated unchanged or worsened rates of
improvement; a limited set of targeted metrics
could thus inhibit the comprehensive function ofTa

bl
e

3.
Co

nt
in

ue
d

D
es
cr
ip
ti
on
P
ro
sp
ec
ti
ve

vs
re

tr
os
pe
ct
iv
e
F
in
an
ci
al
ly
di
sc
ou
ra
ge
s
vo
lu
m
e
of
se
rv
ic

es
?

F
in
an
ci
al
ly
en
co
ur
ag
es
hi
gh
qu
al
it
y
of
ca
re
?
P
ar
ty
th
at
pr

im
ar

ily
be
ar
s
th
e
fi
na
nc
ia
l
ri
sk
?
R
is
k
ad
ju
st
s
fo
r
pa
ti
en
t
co
m
pl
ex
it
y?
K
ey
E
xa
m
pl
e

D
ir

ec
t

pr
im
ar
y
ca
re
P
ai

d
ou

ts
id

e
of

th
ir

d-
pa

rt
y

in
su

re
rs

(o
ft

en
di

re
ct

ly
fr

om
pa

ti
en

ts
)

a
pr

ed
et

r
m

in
ed

am
ou

nt
to

co
ve
r
al

l
pr

im
ar
y
ca

re
se

rv
ic
es
fo
r
a
sp
ec
ifi
c
pe
ri
od
of
ti
m
e
P
ro
sp
ec
ti
ve
Y
es
N
o
P
ri
m
ar
y
ca
re
pr
ac
ti
ce
s
fo
r
pr
im
ar
y
ca
re

ex
pe

ns
es

N
o

Q
lia

nc
e

P
at

ie
nt

s
fo

r
ot

he
r

as
pe

ct
s

of
ca

re
(a

nd
in

su
re

rs
if

pa
ti

en
ts

ha
ve

th
ir

d
pa

rt
y
in
su

ra
nc

e)
A
C
O
,

ac
co

un
ta

bl
e
ca
re
or
ga
ni
za
ti
on

;
H

M
O

,
he

al
th

m
ai

nt
en

an
ce
or
ga
ni
za
ti
on

;
C

M
M

I,
C

en
te

r
fo

r
M

ed
ic

ar
e
an
d
M
ed

ic
ai

d
In

no
va

ti
on
.

592 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://www.jabfm.org/

Ta
bl

e
4.

Im
pa

ct
of

Pr
im
ar
y
Ca
re
Pa
ym
en
t
M
od

el
s

on
th

e
Q

ua
dr

up
le

Ai
m

an
d

Te
ne

ts
of

Pr
im
ar
y
Ca
re
P
ay
m
en

t
M

od
el

Q
ua

dr
up

le
A

im
A

lo
w

s
P

ro
ac

ti
ve

In
ve

st
m

en
t

in
P

ri
m
ar
y
C
ar
e

T
he

4
C

s
of
P
ri
m
ar
y
C
ar
e

E
le

m
en

ts
A

ss
oc

ia
te

d
w

it
h

Su
cc

es
sf

ul
P

ro
gr

am
s

H
ea
lt
h

O
ut

co
m

es
E

xp
er

ie
nc

e
of
C
ar
e
C

os
t

C
on

tr
ol

P
ro

vi
de

r
Sa

ti
sf

ac
ti

on
C

on
ta

ct
(A

cc
es

s)
C

on
ti

nu
it

y
C

oo
rd

in
at

io
n

C
om
pr
eh
en
si

ve
ne

ss
F
ee
-f
or
-s
er
vi
ce

(F
F

S)
2

2
2

2
✕

4
3

1
2

ill
in

g
m

ec
ha

ni
sm

s
av

ai
la

bl
e
th
at
re
co

gn
iz

e
pr
im
ar
y
ca

re
te

ne
ts

an
d

no
n-

fa
ce

-t
o-

fa
ce
se
rv
ic
es
T
ra
di
ti
on
al

(f
ul

l-
ri

sk
)

ca
pi
ta
ti
on
4
3

M
os

tl
y

M
os
tl
y
1
2

✔
2

In
su

ff
.

ev
id

en
ce

In
su
ff
.
ev
id
en
ce
1
2
R
is

k
lim

it
ed

to
pr

im
ar
y
ca
re
se
rv
ic

es
P

M
P

M
de

te
rm

in
at
io
n
ba
se
d
on

an
ti

ci
pa

te
d

ne
ed

ra
th

er
th

an
F

F
S*

P
ay
-f
or

–
pe

rf
or

m
an

ce
(P

4P
)

2
1

2
1
2
1
2
✕
2
1

2
4
3

2
A

pp
ro

pr
ia

te
,

al
ig

ne
d

m
ea
su
re
s
fo

r
us

e
in
pr
im
ar
y
ca
re
*
B
un
dl

ed
pa

ym
en

t
(e

pi
so

de
-o

f-
ca

re
)

4
3

(w
ea

k)
In

su
ff

.
ev

id
en

e
In

su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en

ce
✔

/✕ (r
et

ro
ac
ti
ve

ly
tr

ig
ge

re
d)

In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce

1
(w

ea
k)

In
su
ff
.
ev
id
en
ce

N
/A

,
m

ay
no

t
ap

pl
y

to
pr
im
ar
y
ca

re
gi

ve
n

di
ffi

cu
lt

y
de

fi
ni

ng
an

d
as

si
gn

in
g

bu
nd

le
s

Sh
ar
ed
sa
vi
ng

s
1

1
2
1

In
su
ff
.
ev
id
en
ce

✔
/✕

(p
ro

vi
de

rs
of

te
n
pa
id
F
F
S)
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce

1
*

In
su
ff
.
ev
id
en
ce

T
ar

ge
t

hi
gh

-n
ee

ds
pa

ti
en
ts
A

dd
re

ss
ps

yc
ho

so
ci

al
ne

ed
s

A
pp

ro
pr

ia
te
ri
sk

–
ad

ju
st
m
en

t
N

on
-F

F
S

in
ce

nt
iv

es
at

pr
ov
id
er
le
ve

l*
P

hy
si
ci
an

-l
ed

r
in

te
gr

at
ed

A
C
O
C
on
ti
nu
ed

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 593

http://www.jabfm.org/

Ta
bl
e
4.

Co
nt

in
ue

d
P
ay
m
en
t
M
od
el
Q
ua
dr
up
le
A
im
A
llo
w
s
P
ro
ac
ti
ve
In
ve
st
m
en
t
in
P
ri
m
ar
y
C
ar
e
T
he
4
C
s
of
P
ri
m
ar
y
C
ar
e
E
le
m
en
ts
A
ss
oc
ia
te
d
w
it
h
Su
cc
es
sf
ul
P
ro
gr
am
s
H
ea
lt
h
O
ut
co
m
es
E
xp
er
ie
nc
e
of
C
ar
e
C
os
t
C
on
tr
ol
P
ro
vi
de
r
Sa
ti
sf
ac
ti
on
C
on
ta
ct
(A
cc
es
s)
C
on
ti
nu
it
y
C
oo
rd
in
at
io
n
C
om
pr
eh
en
si
ve
ne
ss
B
le
nd
ed
F
F
S
an
d
ca
pi
ta
ti
on
2
1
2
1
2
1
In
su
ff
.
ev
id
en
ce
✔
/✕

1
1

1
In

su
ff
.
ev
id
en

ce
T

ar
ge

t
hi

gh
-n

ee
ds

pa
ti
en
ts
A
pp
ro
pr
ia
te
ri
sk
–
ad
ju
st
m
en
t
M

ul
ti

pa
ye

r
al

ig
nm

en
t

R
ea

l-
ti

m
e

da
ta

sh
ar

in
g

O
pt

im
al

F
F

S/
ca

pi
ta
ti
on

bl
en

d
(m

or
e

re
se

ar
ch

ne
ed

ed
)

C
om
pr
eh

en
–

si
ve
pr
im
ar
y
ca
re
pa
ym
en
t
1
(w
ea
k)
1
(w
ea
k)
1
(w

k)
1

(w
ea

k)
✔

1
(w
ea
k)
In
su
ff
.

E
vi

de
nc

e
In
su
ff
.
ev
id
en

ce
1

(w
ea

k)
A

pp
ro
pr
ia

te
ri

sk
ad

ju
st
m
en
t
P
ay
m
en
ts
ba
se
d
on

10
%

to
ta

l
co

st
of

ca
re
ra
th
er
th

an
pr

io
r

F
F

S
D

ir
ec

t
pr
im
ar
y
ca

re
In

su
ff
.
ev
id
en
ce
1
(w
ea
k)
1
(w
ea
k)
1
(w
ea
k)
✔
2
1

*
(b

et
te

r
in

di
v.

ac
ce

ss
,

bu
t

af
fo

rd
ab

ili
ty

an
d

w
or

kf
or

ce
co

nc
er

ns
)

In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce

C
ou

pl
in

g
w

it
h

ap
pr

op
ri

at
e

w
ra

pa
ro

un
d

in
su
ra
nc

e
to

av
oi

d
hi

gh
pa

ti
en
t
co

st
s

fo
r
no
n-
pr
im
ar
y
ca
re
se
rv
ic
es
*

1
,

ev
id
en
ce

of
po

si
ti

ve
ou

tc
om

es
.

2
,

ev
id
en
ce

of
ne

ga
ti

ve
ou
tc
om
es
.
2
1

,
ev

id
en

ce
of

m
ix

ed
ef

fe
ct

s.
4
3

,
no

si
gn

ifi
ca

nt
ef

fe
ct

or
ch

an
ge

.
✔

,
al

lo
w

s
pr

oa
ct

iv
e

in
ve

st
m
en
t

in
pr

im
ar
y
ca

re
.

✕
,

do
es
no
t

al
lo

w
pr

oa
ct
iv
e
in
ve
st
m
en
t
in
pr
im
ar
y
ca
re
.
✔
/✕

,
so

m
e
co
m
po
ne
nt
s
al
lo
w
pr
oa
ct
iv
e
in
ve
st
m
en
t
in
pr
im
ar
y
ca

re
,

w
hi

le
ot

he
rs

do
no

t.
In

su
ff
.
ev
id
en

ce
,

no
av

ai
la
bl
e
ev
id
en
ce

;
(w

ea
k)

,
lim

it
ed

or
po

or
qu

al
it

y
ev

id
en

ce
(i

e,
�

1
st

ud
y

ex
am

in
ed

an
d/

or
no

t
a

co
m

pa
ri

so
n

st
ud

y)
.

*N
o

or
lim

it
ed
ev
id
en
ce

,
bu

t
a

st
ro

ng
th

eo
re

ti
ca

l
lik

el
ih

oo
d

of
ef

fe
ct

.
P

ro
ac
ti
ve
in
ve
st
m
en
t
in
pr
im
ar
y
ca

e
ca

n
su

pp
or

t
al

l
of
th
e
4
C

s.
A

C
O

,
ac

co
un

ta
bl

e
ca

re
or

ga
ni

za
ti

on
;

P
M

,
pe

r
m

em
be

r
pe

r
m
on
th
.

594 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://www.jabfm.org/

primary care.41,42 P4P targeted to the 4 Cs could
hypothetically support primary care; however, cur-
rent metrics focus predominantly on disease-fo-
cused and process-oriented outcomes (eg, HbA1c)
outcomes, rather than patient-centered outcomes
(eg, quality of life) or primary care attributes (eg,
continuity).41,43 Metrics for the latter remain un-
derdeveloped and under used,42 despite growing
recognition of the importance of measuring the 4
Cs.45 As P4P is a bonus payment, the shortcomings
of the underlying payment model often prevail.

Overall, the evidence supporting P4P has been
mixed, with inconsistent impacts across the Qua-
druple Aim.41,45,46,47,48,49,50 In 2 large systematic
reviews, 1 from QOF and 1 from the United States,
some modest yet positive impacts on rate of im-
provement for targeted quality and patient out-
comes were observed initially, but these benefits
stagnated over time, if not regressed to preinter-
vention rates.41,51 Providers reported decreased pa-
tient-centered care and continuity41, which are im-
portant predictors of provider satisfaction.52 The
return on investment of P4P may be low, given
significant time and financial costs of implementa-
tion.53

Bundled Payment/Episode-of-Care Payment
Under bundled payment, providers receive a pre-
determined payment for all services rendered for an
episode-of-care; this payment may be provided
prospectively or retrospectively. This model has
been used in hospitals (ie, Diagnosis Related
Groups), which receive a set fee for services (ie,
labor and delivery). As with capitation, providers
are at financial risk if their costs exceed the fee but
profit from cost savings. Bundled payments may be
optimal for high-cost, low-frequency conditions or
episodes (eg, hip fractures), as there is incentive to
limit the costs for the given episode, but not to
limit future episodes.30

Limited evidence exists of the impact of bundled
payment on the 4 Cs. As reimbursements for an
episode of care are bundled for multiple providers,
coordination across specialties is encouraged54,
with improvements demonstrated in a Netherlands
bundled-payment initiative.55 Like capitation,
global payment could support the 4 Cs by enabling
investment in a strong primary care infrastructure.
Unfortunately, bundled payments can be difficult
to implement in primary care due to issues around
defining episodes of care. Although acute condi-

tions like fractures and pregnancy have clearer be-
ginning and end points, defining what constitutes a
chronic condition episode is more challenging, a
problem amplified in patients with multiple chronic
conditions. Furthermore, as a retrospectively trig-
gered but prospectively defined fee, bundled pay-
ment shares some of the disadvantages of both FFS
and capitation. Though costs may be saved within
episodes, there is a financial incentive to increase
episodes, similar to FFS. Because financial incen-
tives are predicated on savings, there may be a
disincentive to care for sicker patients.

Although Diagnosis Related Groups decrease
overall health care expenditures56, evidence for the
use of bundled payments in primary care is limited.
This was evaluated in a 2006 pilot, where none of
the primary care sites were able to implement the
model over 3 years due to challenges in defining an
episode and identifying and tracking included ser-
vices based on FFS claims.57 Data from the Neth-
erlands suggest no significant impact on quality58;
otherwise there is a paucity of evidence for bundled
payment outside of an acute care setting.59 In sum-
mary, there is a lack of evidence on the impact of
bundled payments in primary care on the Quadru-
ple Aim, possibly because the model may not be
applicable to that setting.

Shared Savings
Under shared savings, providers or an accountable
care organization (ACO) are responsible for the
costs and quality of care for a defined population
through the provision of a global budget.60 Most
often, the global budgets are calculated based on
expenditures from prior years and supplied by in-
surers as a risk-adjusted PMPM.61 Expenditures at
the end of 1 year are compared against a bench-
mark, which are also often calculated from expen-
ditures from prior years. Risk arrangements can be
1-sided, where the ACO or equivalent group is
eligible for shared savings if their costs are below
the benchmark and they meet predetermined qual-
ity targets; or they can be 2-sided, where they are
also at risk of penalty if they exceed the bench-
mark.62 As with other global budget arrangements
(eg, capitation, bundled payment), the 2-sided ar-
rangement shifts some financial risk from payers to
the ACO.

Our review of shared savings models found few
evaluations offering insights into their impact on
the 4 Cs. Like other models using global payments,

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 595

http://www.jabfm.org/

shared savings theoretically allows ACOs to invest
upfront in a primary care infrastructure. Like bun-
dled payment, because cost savings are shared
across provider groups, shared savings could im-
prove coordination.63 Shared savings, as it has been
operationalized thus far, may present limitations
for primary care. First, because benchmarks are
often calculated from expenditures from previous
time periods, inefficient, high-spending providers
could be rewarded, while high-functioning, coor-
dinated practices delivering comprehensive care
could receive comparably lower payments. Second,
due to the payment lag from distributing cost sav-
ings retrospectively at the end of the year, practices
may not be able to invest this money upfront in
services that deliver on primary care functions. Fi-
nally, despite being paid by a global budget, many
ACOs continue to reimburse their providers based
on FFS64,65, limiting both the effectiveness of the
model and the benefits reaped at the provider level.

The most significant data examining shared sav-
ings are the preliminary results of 2 CMMI initia-
tives: the Medicare Shared Savings Program
(MSSP; with results currently available for its third
performance year) and the Pioneer ACO (with re-
sults currently available for its fourth performance
year).

In 2015, 392 organizations participated in
MSSP; there were 12 participating organizations in
the Pioneer ACO program. Although 31% of
MSSP and Pioneer ACO practices earned shared
savings, the programs operated at a net loss of $216
million to CMS after accounting for bonus pay-
ments.66 The majority of quality measures im-
proved in 2015.67 There was no significant corre-
lation between quality performance and cost
savings in the MSSP.68 Cost savings were more
likely in ACOs that were smaller and physician-led
or integrated (physician-hospital partnership), had
been participating in the program longer, and had
higher benchmarks. As with many other programs,
although the ACO is paid through a global budget,
many providers continue to be paid via FFS.69,65

Hennepin Health, a safety-net ACO serving
Medicaid enrollees in Minnesota, is a partnership
between federally-qualified health centers, the
county hospital, the county health department, and
a nonprofit HMO.63 The ACO’s model centers
around interdisciplinary primary care teams, and
the flexibility of PMPM funds under the global
budget has been used to address a broader set of

patients’ needs, including behavioral health care
and social services. Early results demonstrate de-
creased emergency department (ED) visits im-
proved quality of chronic disease care and high
patient satisfaction.63 Approximately $3 million in
savings over 3 years has been reinvested in inter-
ventions to meet social needs.63

Across the Quadruple Aim, shared savings seems
to have positive impacts on quality of care and
mixed results on costs; cost savings have been ob-
served in particular when there is physician leader-
ship in the ACO, the ACO has been in existence for
a longer period of time, and care coordination and
inclusion of nonmedical services are emphasized.
Continued FFS payments at the provider level may
limit benefits.

Blended FFS and Capitation
Capitated PMPM payments are given in addition
to FFS in the form of care management fees, care
coordination fees, or patient-centered medical
home (PCMH) payments in blended payment
models. These fees are intended to finance PCMH
infrastructure, staffing, and services not covered by
reimbursement for traditional office visits, particu-
larly activities that coordinate care across the health
care system. These fees may be adjusted to dimin-
ish the risk of cherry-picking. By adjusting payment
systems that are already in place, blended FFS and
capitation may present fewer barriers to widespread
implementation than models that require systemic
overhaul.

The largest source of emerging evidence regard-
ing impact of blended FFS and capitation in the
primary care setting comes from 2 large Medicare
demonstration projects: the Comprehensive Pri-
mary Care Initiative (CPCI) and the Multi-Payer
Advanced Primary Care Practice (MAPCP). In the
third year of CPCI, improvements in care access
and continuity were observed.70 The capitated
PMPM payments could allow practices to proac-
tively invest in an infrastructure that supports pri-
mary care, and practices implementing risk-adjust-
ment could guard against cherry-picking. As
capitation and FFS often have opposite effects,
blending the 2 models could mitigate the short-
comings of each; however, as the PMPMs support-
ing PCMH services are often disproportionately
smaller than FFS payments71, the incentive for
higher volumes of services may predominate.

596 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://www.jabfm.org/

Results from the first 3 years of CPCI, encom-
passing 445 primary care practices, over 2100 pro-
viders, and nearly 2.9 million patients in 7 regions,
show practices have not yet achieved cost savings.72

Statistically significant reductions were noted in
expenditures for skilled nursing facilities (5%), pri-
mary care services (2%), and outpatient services
(2%). ED visits were significantly reduced in the
CPCI group, but decreases in hospitalization did
not reach statistical significance. However, after
including care management fees, Medicare expen-
ditures increased by $7 PMPM more for CPCI
than comparison practices. Most quality of care
measures did not change, with the exception of
small improvements in some measures of diabetes
care quality and likelihood of ED revisit.

The MAPCP demonstration project started in
2011, involving 8 states, approximately 850 primary
care practices, over 6300 providers, and about
712,000 Medicare beneficiaries.70 In all 8 states,
Medicare, Medicaid, and private health plans are
participating. Preliminary results from the second
(with cost saving estimates) and third year are avail-
able for MAPCP. Only Michigan demonstrated
significant net savings after accounting for demon-
stration fees paid out to each state for MAPCP
participation. Significant heterogeneity in PMPM
payments exists among the MAPCP group, ranging
from $1.20 to $60.81.70

Quality outcomes and utilization for MAPCP
have been mixed. In the second year evaluation, 5
out of 8 states had some improvement in guideline-
recommended services for diabetes, while in 2
states these measures declined.70 Similarly, in 6 out
of 8 states, there were no significant differences
found in preventable hospitalizations; in 2 states,
there were increases observed.70 In the third year,
some commercial payers and Medicaid in New
York and Vermont reported reductions in hospi-
talizations and ED visits, with some payers finding
a decrease in total PMPM costs.

Other studies in our review found similarly
mixed Quadruple Aim outcomes for blended FFS
and capitation models.73,74,75,76 Commonalities
across more effective programs include being in
place for a longer period of time, multipayer align-
ment77, focusing on high-cost patients78,79,80,81,
and investing in population health data systems that
provide real-time information on health care
use.80,81,82 Some experts have suggested blended

FFS and capitation as a transition to fully global
budgets.83,84

Comprehensive Primary Care Payment
Like traditional capitation, under comprehensive
primary care payment, insurers provide a prospec-
tive payment to cover all primary care services
within a specific period of time (eg, PMPM).
Rather than basing capitated payments on historic
FFS reimbursements, these payments are calcu-
lated to account for the delivery of primary care
services and costs necessary to support medical
homes. To address cherry-picking, comprehen-
sive primary care payments are risk-adjusted
based on patient complexity and include a com-
ponent of P4P to address concerns about poten-
tial inappropriate under use of services. Further-
more, PCPs are financially responsible for primary
care expenditures rather than total costs, relieving
some of the financial risk seen in traditional capi-
tation and transferring part of the risk to payers30;
however, providers continue to maintain some fi-
nancial accountability.

Relatively little evidence exists for the impact of
comprehensive primary care payment on the Qua-
druple Aim or the 4 Cs. Like other prospective
models, the model allows for flexible, proactive
investments in a primary care infrastructure that
could support the 4 Cs. Unlike traditional capita-
tion, however, the risk-adjustment of compre-
hensive primary care payment may guard against
cherry-picking and continue to facilitate access
for high-complexity patients. Although the capi-
tated model could hinder comprehensive care by
incentivizing underdelivery of services, linkages to
quality of care in this model through P4P, if ap-
propriate measures for primary care are employed,
could hypothetically guard against inappropriate
underdelivery of care.

Most of the evidence on comprehensive primary
care payment comes from Iora Health4, a national
network of primary care practices, which receives a
fixed, risk-adjusted PMPM from large self-insured
employers, unions, or insurers, and incorporates
additional payments for meeting quality or use tar-
gets.85,86 Ten percent of the total cost of care is
invested in primary care services, roughly doubling

4Iora Health has also opened one DPC practice; a second
DPC practice, Turntable Health, closed in January 2017.

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 597

http://www.jabfm.org/

the percentage the US health care system spends
on primary care.87 These primary care investments
enable Iora to redesign care delivery, such as in-
creasing access (eg, same-day appointments, e-mail
contacts) and comprehensiveness (eg, personal
health coaches).90 Furthermore, the group devel-
oped its own electronic health record to enhance
quality monitoring and performance feedback.
There have not been independent evaluations of
outcomes, but Iora reports increased patient and
provider satisfaction, improvements in blood pres-
sure and HbA1c, a 12.3% decrease in health care
expenditures, a 48% reduction in ER visits, and a
41% reduction in inpatient admissions.85,88

Direct Primary Care (DPC)
DPC has emerged as a model outside of the insur-
ance system attempting to reorganize both the de-
livery and payment of health care to enable the
primary care function.4 In DPC, patients pay the
provider directly, without third-party billing; defi-
nitions vary on whether or not employers paying
providers directly also fall under this model. Pa-
tients are charged a fixed, age-adjusted monthly fee
for all their primary care, independent of preexist-
ing medical conditions.89 Common ancillary ser-
vices are generally provided as part of the monthly
fee, including on-site lab tests, x-rays, and electro-
cardiograms.

There is limited evidence on the potential im-
pact of DPC on specific primary care functions.
DPC providers have increased visit lengths (typi-
cally 30 minutes to 60 minutes per visit), which
could support coordination of care and allow for
greater comprehensiveness.90 Decreased volume of
face-to-face visits has increased time for access via
e-mail and telephone communications.91 As with
other prospective payment models not linked to
volume, DPC grants practices the flexibility to in-
vest revenue in nonvisit-based services that support
primary care.

Some concerns have emerged about the ways
DPC could inhibit the 4 Cs. First, there is the
potential for high cost-sharing90, as the DPC fee
covers only outpatient primary care services. Sec-
ond, DPC may limit access for individuals of lower

socioeconomic status, although DPC groups have
explored arrangements with Medicaid to cover
these patients (by definition, however, this would
no longer constitute a DPC payment arrange-
ment).89 Because DPC panels are one-fifth the size
of non-DPC providers, there are concerns that
expanding the model would decrease access by
compounding the PCP shortage.90

Like comprehensive primary care, few studies
exist that examine the impact of DPC on the
Quadruple Aim. Most of the available evidence
comes from Qliance, a Seattle-based DPC net-
work. Qliance reported 35% fewer hospitaliza-
tions, 65% fewer ED visits, and 66% fewer spe-
cialist visits.92 In addition, they estimated cost
savings of 19.6% per patient per year and scored at
the 95th percentile for patient experience.93

Qliance recently closed its doors due to financial
difficulties, raising concerns about the financial sus-
tainability of DPC, although this may be related to
efforts to rapidly scale the model.

Discussion
Our review identified 8 distinct payment models
which differentially shape primary care delivery in
the United States: FFS, traditional capitation, P4P,
bundled payment, shared savings, blended FFS and
capitation, comprehensive primary care payment,
and DPC; many payers use combinations of these
models. Each model is currently in various stages of
implementation, with significantly less evidence
available for newer models.

Few studies examined the impact of payment
models on the 4 Cs of primary care. Nonetheless,
several key characteristics were consistently noted.
First, payment models can be viewed along a spec-
trum from FFS (retrospective) to capitated (pro-
spective) payment. Whereas retrospective payment
may incentivize the delivery of services, prospective
payments offer flexibility for primary care practices
to invest in services and infrastructure that can
enhance the 4 Cs, such as nursing follow-up calls to
enhance coordination, same-day appointments to
improve access, and integrated behavioral health
for more comprehensive care. Second, because
capitated models may encourage adverse selection
and underdelivery of appropriate services, risk-ad-
justment may be used to preserve the primary care
attributes of access and comprehensive care, re-
spectively. Third, P4P has been used as a bonus to

5DPC differs from concierge medicine in that concierge
practices continue to bill insurance for services, but also
charge a retainer (usually annually, and significantly higher
than DPC payments) to patients.

598 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://www.jabfm.org/

incentivize quality; however, measures are largely
disease-oriented and generally do not assess the
tenets of primary care or patient-centered out-
comes. Finally, newer payment models have prior-
itized sufficient funds to support primary care ser-
vices that uphold the 4 Cs, but inpatient and
specialty services are paid for separately. Although
in a prospective payment model this may reduce
the financial risk to providers, ongoing research
will be needed to assess whether doing so limits
coordination (eg, incentives not aligned across pri-
mary care and specialty care, or inpatient and out-
patient settings). Studies that examine the role of
and optimal payment for PCMHs within ACOs
may be particularly useful.94

These principles, and the evidence available for
payment models, provide cross-cutting lessons that
guide the following recommendations for the fu-
ture of primary care payment.

Implement and Research Payment Models Based in
PMPMs for Primary Care
Despite the shift from volume to value, FFS re-
mains the dominant model95 As the United States
transitions away from FFS, more primary care pay-
ment models based in prospective payment should
be implemented. The most promising evidence
across the Quadruple Aim came from comprehen-
sive primary care payment and DPC. Both models
use prospective fees that allow practices to tailor
services to the needs of their communities and
proactively implement a primary care infrastruc-
ture supporting the 4 Cs. However, evidence for
both models is generally lacking, so ongoing re-
search is critical. Recently, the Physician-Focused
Payment Model Technical Advisory Committee
recommended testing the American Academy of
Family Physicians’ proposed Advanced Primary
Care APM. This primary care payment model in-
cludes a risk-adjusted PMPM along with P4P (es-
sentially, comprehensive primary care payment)
that could impact 30 million Medicare patients.96

Risk-Adjusted Payments to Ensure Access for All
Populations to Primary Care
Risk-adjusted payments can protect against cherry-
picking healthier patients that negatively impacts
access and also decreases financial risk to providers,
which could improve satisfaction. It is difficult to
assess the impact of risk-adjustment alone however,
as it is a single component of a more complex

model, and significant heterogeneity exists in how
payments are risk-adjusted. Nonetheless, several
risk-adjusted payment models in our review
found decreased health care costs/use for high-
needs, high-using populations.97,98,99,80,100 More
research is needed to validate risk-adjustment
tools.101

Broaden Investments in Primary Care to Include
Behavioral Health and Social Services
One safety-net ACO in our review supporting
comprehensive care inclusive of social and behav-
ioral needs demonstrated significant promise.
CMS’s Accountable Health Communities demon-
stration project provides another opportunity to
research the effect of varying levels of medical-
social services partnerships on costs and use.102

This initiative aims to connect medical and social
services by creating a community-based system that
identifies social barriers to health in the clinical
setting and enables referrals to appropriate com-
munity services.103 More research of similar mod-
els is needed to understand how data, costs, and
risks can be shared across a truly integrated medi-
cal-social neighborhood.

Connect Payments to Performance on Patient-
Centered and Primary Care-Centered Metrics
P4P studies in our review demonstrated inconsis-
tent and mixed results on the Quadruple Aim and
the 4 Cs. The overwhelming majority of quality
metrics are disease-oriented measures, and the
remaining measures largely focused on process
measures and adherence to evidence-based
guidelines104, rather than health outcomes.105

We recommend, as Dr. Starfield did in response
to the QOF, connecting payments to metrics that
capture how well a practice delivers the 4 Cs and
improve patient-centered outcomes, to better ac-
count for multimorbidity and the contexts of pa-
tients’ lives.106

Both the complexity of primary care and the
administrative burden of measurement stand as
barriers to adequately evaluating the 4 Cs.107 Al-
ready, the health care system pays $15.4 billion
annually to measure quality metrics.108 Early
brightspots exist in evaluating some of the attri-
butes of primary care, such as continuity109, com-
prehensiveness110, and contact111, as well as pa-
tient-centered outcomes19, but much more work
remains in developing those measures and confirm-

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 599

http://www.jabfm.org/

ing their validity across various populations.112 We
support the recommendations of others for more
research to create metrics that effectively measure
primary care113, health information technology to
capture those metrics114, and a national organiza-
tion that validates, disseminates, and implements
these measures.115

Rapid Dissemination and Research is Necessary in
Emerging Primary Care Payment Models
Our review revealed several remaining areas for
research in primary care payment. Evidence is par-
ticularly limited regarding provider satisfaction and
comprehensiveness, and the emerging primary care
payment models (eg, comprehensive primary care,
DPC) lack independent evaluation of their impact
on the Quadruple Aim. Furthermore, the majority
of models in our review demonstrated mixed re-
sults, pointing to the need for ongoing research in
variation of Quadruple Aim outcomes within each
model that could elucidate which factors (eg, clin-
ical characteristics/settings, payer characteristics,
variations in payment amounts) most impact out-
comes, and accounting for how payment impacts
delivery of care.

Limitations
As a narrative review, our search may not have
captured all the relevant evidence. Similarly, a qual-
ity assessment was not conducted, although articles
with higher levels of evidence (eg, systematic re-
views) were prioritized. Furthermore, our recom-
mendations were guided by seminal examples of
these models of the main payment models repre-
sented in US health care, rather than strictly
through randomized control trials, which do not
exist for the majority of the models reviewed.
Given this, as well as significant heterogeneity in
study design, populations, delivery settings, and
metrics evaluated, standard quantitative summary
methods were not possible. Finally, although our
review focused on payment models, significant het-
erogeneity in the delivery and services stemming
from the payment structure is a possible con-
founder to interpreting our results; however,
changes in payment enable changes in delivery, and
in many instances, it may be difficult to separate
their effects.

Conclusion
Evidence from Starfield and others2–15 supports the
central role of primary care in high-performing
health systems and the achievement of population
health goals. Effective payment for primary care
delivery, supportive of the 4 Cs, can lead to achiev-
ing the Quadruple Aim. Findings from this review
can help guide future implementation and research
efforts to successfully shift away from a FFS model
that has inhibited primary care. MACRA, through
its support of APMs, as well as a host of multipayer
initiatives such as the CMMI’s Comprehensive Pri-
mary Care Plus demonstration project and the
American Academy of Family Physicians’s Ad-
vanced Primary Care APM, signal an opportunity
for the US health care system to continue the
transition from volume-based to value-based
care. Increasing investments into primary care is
necessary but not sufficient for improving health
care; how we invest in a comprehensive primary
care infrastructure—spanning health care deliv-
ery, research, practice transformation support,
and HIT—to evolve how care is both delivered
and measured will be critical.

The authors gratefully acknowledge the support of Family Med-
icine for America’s Health, along with the additional sponsors of
the Starfield Summit, the Pisacano Leadership Foundation, and
the American Board of Family Medicine.

To see this article online, please go to: http://jabfm.org/content/
31/4/588.full.

References
1. World Health Organization. Declaration of Al-

ma-Ata. International Conference on Primary
Health Care, Alma-Ata, USSR, 6 –12. September
1978. Available from: URL: http://www.who.int/
publications/almaata_declaration_en .

2. Starfield B, Shi L. Policy relevant determinants of
health: an international perspective. Health Policy
2002;60:202–21.

3. Shi L, Macinko J, Starfield B, Politzer R, Xu J.
Primary care, race, and mortality in U.S. states.
Social science & medicine 2005;61:65–75.

4. Starfield B, Shi L, Macinko J. Contribution of pri-
mary care to health systems and health. Milbank Q
2005;83:457–502.

5. Kringos DS, Boerma WG, Hutchinson A, van der
Zee J, Groenewegen PP. The breadth of primary
care: a systematic literature review of its core di-
mensions. BMC Health Serv Res 2010;10:65.

6. Friedberg MW, Hussey PS, Schneider EC. Pri-
mary care: a critical review of the evidence on qual-

600 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://jabfm.org/content/31/4/588.full

http://www.who.int/publications/almaata_declaration_en

http://www.jabfm.org/

ity and costs of health care. Health Aff 2010;29:
766 –72.

7. Shi L. The impact of primary care: a focused re-
view. Scientifica 2012.

8. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family phy-
sicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med 2015;13:206 –13.

9. Organization for Economic Co-operation and De-
velopment (2014). OECD health data 2014: how
does the United States compare? The Organization
for Economic Co-operation and Development.
Paris, France. Available from: http://www.oecd.
org/unitedstates/BriefingNoteUSA2014 . Published
2014. Accessed March 4, 2016. Available from: http://
www.oecd.org/unitedstates/Briefing-Note-UNITED-
STATES-2014 .

10. Berwick DM, Hackbarth AD. Eliminating waste in
U.S. health care. JAMA 2012;307:1513– 6.

11. Mossialos E, Wenzl M, Osborn R, Anderson C.
International profiles of health care systems, 2014.
New York (NY): The Commonwealth Fund; 2015.

12. National Research Council, Institute of Medicine.
US Health in international perspective: shorter
lives, poorer health. Washington, DC: National
Academies Press; 2013.

13. The Institute of Medicine. U.S. health in interna-
tional perspective: shorter lives, poorer health. Wash-
ington, DC: The National Academies Press; 2013.

14. Bodenheimer T, Sinsky C. From triple to quadru-
ple aim: care of the patient requires care of the
provider. Ann Fam Med 2014;12:573– 6.

15. Woolf SH, Aron LY. The US health disadvantage
relative to other high-income countries: findings
from a National Research Council/Institute of
Medicine report. JAMA 2013;309:771–2.

16. Phillips RL Jr., Bazemore AW. Primary care and
why it matters for US health system reform. Health
Aff (Millwood) 2010;29:806 –10.

17. Goroll AH, Berenson RA, Schoenbaum SC, Gard-
ner LB. Fundamental reform of payment for adult
primary care: comprehensive payment for compre-
hensive care. J Gen Intern Med 2007;22:410 –5.

18. World Health Organization (WHO). Health sys-
tem financing. Geneva: WHO; 2010. P. 72–5.

19. Rollow W, Cucchiara P. Achieving value in primary
care: the primary care value model. Ann Fam Med
2016;14:159 – 65.

20. Patient Protection and Affordable Care Act, 42
U.S.C. § 18001; 2010.

21. Davis K, Abrams M, Stremikis K. How the Afford-
able Care Act will strengthen the nation’s primary
care foundation. J Gen Intern Med 2011;26:1201.

22. Center for Medicare & Medicaid Services. About
the CMS Innovation Center. Available from: https://
innovation.cms.gov/About/index.html. Published
2015. Accessed March 30, 2016.

23. Centers for Medicare & Medicaid Services (CMS).
Medicare Program; Merit-Based Incentive Pay-
ment System (MIPS) and Alternative Payment
Model (APM) incentive under the physician fee
schedule, and criteria for physician-focused pay-
ment models. Final rule with comment period. Fed-
eral register 81.214 (2016): 77008. Available from:
https://www.federalregister.gov/documents/2016/11/
04/2016 –25240/medicare-program-merit-based-
incentive-payment-system-mips-and-alternative-
payment-model-apm. Accessed January 06, 2018.

24. Stange KC, Nutting PA, Miller WL, et al. Defining
and measuring the patient-centered medical home.
J Gen Intern Med 2010;25:601–12.

25. Doohan N, Coutinho AJ, Lochner J, Wohler D,
DeVoe J. “A Paradox Persists When the Paradigm
Is Wrong”: Pisacano scholars’ reflections from the
inaugural Starfield Summit. J Am Board Fam Med
2016;29:793– 804.

26. Grant MJ, Booth A. A typology of reviews: an
analysis of 14 review types and associated method-
ologies. Health Info Libr J 2009;26:91–108.

27. Goodson JD. Unintended consequences of re-
source-based relative value scale reimbursement.
JAMA 2007;298:2308 –10.

28. Sinksy CA, Dugdale DC. Medicare payment for
cognitive vs procedural care: minding the gap.
JAMA Intern Med 2013;173:1733–7.

29. Miller HD. From volume to value: better ways to
pay for health care. Health Aff 2009;28:1418 –28.

30. Draper DA, Hurley RE, Lesser CS, Strunk BC.
The changing face of managed care. Health Aff
2002;21:11–23.

31. Rice N, Smith PC. Capitation and risk adjustment
in health care financing: an international progress
report. Milbank Q 2001;79:81–113.

32. Pope GC, Kautter J, Ellis RP, et al. Risk adjustment
of Medicare capitation payments using the CMS-
HCC model. Health Care Financ Rev 2004;25:119.

33. Miller RH, Luft HS. HMO plan performance up-
date: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.

34. Llanos K, Rothstein J. Physician pay-for-perfor-
mance in Medicaid: a guide for states. Center for
Health Care Strategies, Incorporated; 2007.

35. Miller RH, Luft H S. HMO plan performance
update: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.

36. Miller RH, Luft HS. Does managed care lead to better
or worse quality of care? Health Aff 1997;16:7–25.

37. Berwick DM. Payment by capitation and the qual-
ity of care. N Engl J Med 1996;335:1227–31.

38. Miller RH, Luft HS. HMO plan performance up-
date: an analysis of the literature, 1997–2001.
Health Aff 2002;21:63– 86.

39. Llanos K, Rothstein J. Physician pay-for-perfor-
mance in Medicaid: a guide for states. Center for
Health Care Strategies, Incorporated 2007.

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 601

http://www.oecd.org/unitedstates/BriefingNoteUSA2014

http://www.oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014

https://innovation.cms.gov/About/index.html

https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm

http://www.jabfm.org/

40. Gillam SJ, Siriwardena AN, Steel N. Pay-for-per-
formance in the United Kingdom: impact of the
quality and outcomes framework—a systematic re-
view. Ann Fam Med 2012;10:461– 8.

41. Roland M, Campbell S. Successes and failures of
pay for performance in the United Kingdom.
N Engl J Med 2014;370:1944 –9.

42. Doran T, Kontopantelis E, Valderas JM, et al.
Effect of financial incentives on incentivized and
non-incentivised clinical activities: longitudinal
analysis of data from the UK Quality and Outcomes
Framework. BMJ 2011;342:d3590.

43. Starfield B, Mangin D. An international perspective
on the basis of pay-for-performance. The Quality
and Outcomes Framework: QOF-Transforming
General Practice 2016;147.

44. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family phy-
sicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med, 2015;13:206 –13.

45. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early
experience with pay-for-performance: from con-
cept to practice. JAMA 2005;294:1788 –93.

46. Lemak CH, Nahra TA, Cohen GR, et al. Michi-
gan’s fee-for-value physician incentive program re-
duces spending and improves quality in primary
care. Health Aff 2015;34:645–52.

47. Scott A, Sivey P, Ait Ouakrim D, et al. (2011). The
effect of financial incentives on the quality of health
care provided by primary care physicians. Cochrane
Database Syst Rev 2011:9.

48. Eccles MP, Shepperd S, Scott A, Flodgren G, Par-
melli E, Beyer FR. An overview of reviews evaluat-
ing the effects of financial incentives in changing
healthcare professional behaviours and patient out-
comes. The Cochrane Library; 2010.

49. Nelson, L. Lessons from Medicare’s demonstration
projects on value-based payment. Congressional
Budget Office, Working Paper, 2012;2.

50. Marshall L, Charlesworth A, & Hurst J. The NHS
payment system: evolving policy and emerging ev-
idence. London: The Nuffield Trust; 2014.

51. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of
financial incentives on the quality of health care
provided by primary care physicians. Cochrane Da-
tabase Syst Rev 2011;9(9).

52. Mittelstaedt TS, Mori M, Lambert WE, Saultz JW.
Provider practice characteristics that promote in-
terpersonal continuity. J Am Board Fam Med 2013;
26:356 – 65.

53. Roland M, & Guthrie B. Quality and outcomes frame-
work: what have we learnt? BMJ 2016;354:i4060.

54. de Bakker DH, Struijs JN, Baan CA, et al. Early
results from adoption of bundled payment for dia-
betes care in the Netherlands show improvement in
care coordination. Health Aff 2012;31:426 –33.

55. de Bakker DH, Struijs JN, Baan CB, et al. Early
results from adoption of bundled payment for dia-

betes care in the Netherlands show improvement in
care coordination. Health Aff (Millwood) 2012;31:
426 –33.

56. Bertko, J, Effros, R. Analysis of Bundled Payment.
RAND Health COMPARE. Available from: http://
www.rand.org/pubs/technical_reports/TR562z20/
analysis-of-bundled-payment.html. Published 2010.
Accessed March 9, 2016.

57. Hussey PS, Ridgely MS, Rosenthal MB. The PRO-
METHEUS bundled payment experiment: slow
start shows problems in implementing new pay-
ment models. Health Aff 2011;30:2116 –24.

58. Wesselink SFO, Lingsma HF, Ketelaars CAJ,
Mackenbach JP, Robben PBM. Effects of govern-
ment supervision on quality of integrated diabetes
care: a cluster randomized controlled trial. Med
Care 2015;53:784 –91.

59. Wojtak A, Purbhoo D. Perspectives on advancing
bundled payment in Ontario’s home care system
and beyond. Healthcare Q 2015;18:18 –25.

60. Hayen AP, van den Berg MJ, Meijboom BR, Struijs
JN, Westert GP. Incorporating shared savings pro-
grams into primary care: from theory to practice.
BMC Health Serv Res 2015;15:580.

61. Hayen AP, van den Berg MJ, Meijboom BR, Struijs
JN, Westert GP. Incorporating shared savings pro-
grams into primary care: from theory to practice.
BMC Health Serv Res 2015;15:580.

61. Barnes AJ, Unruh L, Chukmaitov A, van Ginneken
E. Accountable care organizations in the USA:
types, developments and challenges. Health Policy
2014;118:1–7.

63. Sandberg SF, Erikson C, Owen R, et al. Hennepin
Health: a safety-net accountable care organization
for the expanded Medicaid population. Health Aff
2014;33:1975– 84.

64. Goroll AH, Schoenbaum SC (2012). Payment re-
form for primary care within the accountable care
organization: a critical issue for health system re-
form. JAMA 2012;308:577– 8.

65. Muhlestein DB, Croshaw AA, Merrill T P (2013).
Risk bearing and use of fee-for-service billing
among accountable care organizations. Am J Manag
Care 2013;19:589 –92.

66. Jha, A. ACO winners and losers: a quick take. The
Health Care Blog. Available from: http://thehealth
careblog.com/blog/2016/08/30/aco-winners-and-
losers-a-quick-take/. Published August 30, 2016.
Accessed December 3, 2016.

67. Medicare ACOs: incremental progress, but perfor-
mance varies. Available from: http://healthaffairs.
org/blog/2016/09/21/medicare-acos-incremental-

progress-but-performance-varies/. Published Sep-
tember 21, 2016. Accessed December 03, 2016.

68. Medicare ACOs: incremental progress, but perfor-
mance varies. Available from: http://healthaffairs.
org/blog/2016/09/21/medicare-acos-incremental-

602 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

http://www.rand.org/pubs/technical_reports/TR562z20/analysis-of-bundled-payment.html

ACO Winners and Losers: A Quick Take

http://healthaffairs.org/blog/2016/09/21/medicare-acos-incremental-progress-but-performance-varies/

http://www.jabfm.org/

progress-but-performance-varies/. Published Sep-
tember 21, 2016. Accessed December 03, 2016.

69. Goroll AH, Schoenbaum SC. Payment reform for
primary care within the accountable care organiza-
tion: a critical issue for health system reform. JAMA
2012; 308:577– 8.

70. RTI International. Evaluation of the multi-payer
advanced primary care practice (MAPCP) demon-
stration, third annual report. Available from:
https://downloads.cms.gov/files/cmmi/mapcp-
thirdevalrpt . Published 2016. Accessed January
30, 2017.

71. Merrell K, Berenson RA. Structuring payment for
medical homes. Health Aff 2010;29:852– 8.

72. Peikes D, Swankoski K, Mutti A,et al. Evaluation of
the Comprehensive Primary Care initiative: third
annual report. Available from: https://innovation.
cms.gov/Files/reports/cpci-evalrpt3 . Published
2016. Accessed January 30, 2017.

73. Werner RM, Duggan M, Duey K, Zhu J, Stuart
EA. The patient-centered medical home: an evalu-
ation of a single private payer demonstration in
New Jersey. Med Care 2013;51:487–93.

74. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medi-
care coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.

75. Lemak CH, Nahra TA, Cohen GR, et al. Michi-
gan’s fee-for-value physician incentive program re-
duces spending and improves quality in primary
care. Health Aff 2015;34:645–52.

76. Jabbarpour Y, DeMarchis E, Bazemore A, Grundy
P. The impact of primary care practice transforma-
tion on cost, quality, and utilization: a systemic
review of research published in 2016. Patient-Cen-
tered Primary Care Collaborative July, Washing-
ton, DC; 2017.

77. Nielsen M, Buelt L, Patel K, Nichols LM. The
Patient-Centered Medical Home’s impact on cost
and quality: annual review of the evidence 2014 –
2015. Patient-Centered Primary Care Collabora-
tive, Washington DC; 2016.

78. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medi-
care coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.

79. Fillmore H, DuBard CA, Ritter GA, Jackson CT.
Health care savings with the patient-centered med-
ical home: community care of North Carolina’s
experience. Popul Health Manag 2014;17:141– 8.

80. Koshy RA, Conrad DA, Grembowski D. Lessons
from Washington state’s medical home payment
pilot: what it will take to change American health
care. Popul Health Manag 2015;18:237– 45.

81. Phillips RL, Han M, Petterson SM, Makaroff LA,
Liaw WR. Cost, utilization, and quality of care: an
evaluation of Illinois’ Medicaid primary care case man-
agement program. Ann Fam Med, 2014;12:408 –17.

82. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medi-
care coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.

83. Goroll A, Bagley B, Harbrecht M, Kirschner N,
Kenkeremath N. Payment reform to support high-
performing practice. Report of the Payment Re-
form Task Force of the Patient-Centered Primary
Care Collaborative. Washington, DC: Patient-
Centered Primary Care Collaborative; 2010.

84. Goroll AH. Payment reform to support lasting
practice reform in primary care. J Ambul Care
Manage 2011;34:33–7.

85. Fernandopulle R. Learning to fly: building de novo
medical home practices to improve experience, out-
comes, and affordability. J Ambul Care Manage
2013;36:121–5.

86. Fernandopulle, R. Breaking the fee-for-service ad-
diction: let’s move to a comprehensive primary care
payment model. Health Affairs Blog. Available
from: http://healthaffairs.org/blog/2015/08/17/
breaking-the-fee-for-service-addiction-lets-move-
to-a-comprehensive-primary-care-payment-model/.
Published August 17, 2015. Accessed March 10, 2016.

87. Phillips RL, Bazemore AW. Primary care and why
it matters for US health system reform. Health Aff
2010;29:806 –10.

88. Fernandopulle, R. To cure physician burnout, un-
burden doctors. AthenaInsight. Available from:
https://www.athenahealth.com/insight/to-cure-
physician-burnout-unburden-doctors/. Published 2016.
Accessed February 13, 2018.

89. Wu WN, Bliss G, Bliss EB, Green LA. A direct
primary care medical home: the Qliance experi-
ence. Health Aff 2010;29:959 – 62.

90. McCorry D. Direct primary care: an innovative
alternative to conventional health insurance. Back-
grounder 2014;2939:1–13.

91. Wu WN, Bliss G, Bliss EB, Green L. A. A direct
primary care medical home: the Qliance experi-
ence. Health Aff 2010;29:959 – 62.

92. Page L. The rise and further rise of concierge
medicine. BMJ 2013;347:f6465.

93. Qliance. Direct primary care model delivers 20
percent lower overall healthcare costs, increases pa-
tient satisfaction and delivers better care. PRNews-
wire. Available from: http://www.prnewswire.com/
news-releases/new-primary-care-model-delivers-
20-percent-lower-overall-healthcare-costs-increases-
patient-satisfaction-and-delivers-better-care-
300021116.html. Published January 15, 2015. Ac-
cessed March 11, 2015.

94. Edwards ST, Abrams MK, Baron RJ, et al. Struc-
turing payment to medical homes after the Afford-
able Care Act. J Gen Intern Med 2014;29:1410 –3.

95. Zuvekas SH, Cohen J. W. Fee-for-service, while much
maligned, remains the dominant payment method for
physician visits. Health Aff 2016;35:411– 4.

doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’ Impact on the Quadruple Aim 603

http://healthaffairs.org/blog/2016/09/21/medicare-acos-incremental-progress-but-performance-varies/

https://downloads.cms.gov/files/cmmi/mapcp-thirdevalrpt

https://innovation.cms.gov/Files/reports/cpci-evalrpt3

http://healthaffairs.org/blog/2015/08/17/breaking-the-fee-for-service-addiction-lets-move-to-a-comprehensive-primary-care-payment-model/

https://www.athenahealth.com/insight/to-cure-physician-burnout-unburden-doctors/

http://www.prnewswire.com/news-releases/new-primary-care-model-delivers-20-percent-lower-overall-healthcare-costs-increases-patient-satisfaction-and-delivers-better-care-300021116.html

http://www.jabfm.org/

96. The American Academy of Family Physicians.
Advanced primary care: a foundational alterna-
tive payment model (APC-APM) for delivering
patient-centered, longitudinal, and coordinated
care. Available from: https://www.aafp.org/dam/
AAFP/documents/advocacy/payment/apms/PR-
PTAC-APC-APM-41417 . Published April 14,
2017. Accessed January 22, 2018.

97. Sandberg SF, Erikson C, Owen R, et al. Hennepin
Health: a safety-net accountable care organization
for the expanded Medicaid population. Health Aff
2014;33:1975– 84.

98. Liaw W, Moore M, Iko C, Bazemore A. Lessons
for primary care from the first ten years of Medi-
care coordinated care demonstration projects. J Am
Board Fam Med 2015;28:556 – 64.

99. Fillmore H, DuBard CA, Ritter GA, Jackson CT.
Health care savings with the patient-centered med-
ical home: community care of North Carolina’s
experience. Popul Health Manage 2014;17:141– 8.

100. Phillips RL, Han M, Petterson SM, et al. Cost,
utilization, and quality of care: an evaluation of
Illinois’ Medicaid primary care case management
program. Ann Fam Med 2014;12:408 –17.

101. Thomas JW, Grazier KL, Ward K. (2004). Eco-
nomic Profiling of Primary Care Physicians: Con-
sistency among Risk-Adjusted Measures. Health
Serv Res 2004;39:985–1004.

102. Center for Medicare & Medicaid Services. Ac-
countable health communities model. Available
from: https://innovation.cms.gov/initiatives/ahcm/.
Published February 17, 2017.

103. Alley DE, Asomugha CN, Conway PH, Sanghavi
DM. Accountable health communities—addressing
social needs through Medicare and Medicaid.
N Engl J Med, 2016;374:8 –11.

104. Porter ME, Larsson S, Lee TH. Standardizing pa-
tient outcomes measurement. N Engl J Med 2016;
374:504 – 6.

105. Casalino LP, Gans D, Weber R, et al. US physician
practices spend more than $15.4 billion annually to
report quality measures. Health Aff 2016;35:401– 6.

106. Starfield B, Mangin D. An international perspective
on the basis of pay-for-performance. The Quality
and Outcomes Framework: QOF-Transforming
General Practice, 2016;147.

107. O’Malley AS, Rich EC, Maccarone A, DesRoches
CM, Reid RJ. Disentangling the linkage of primary
care features to patient outcomes: a review of cur-
rent literature, data sources, and measurement
needs. J Gen Intern Med 2015;30:576 – 85.

108. Casalino LP, Gans D, Weber R, et al. US physician
practices spend more than $15.4 billion annually to
report quality measures. Health Aff 2016;35:401– 6.

109. Saultz JW. Defining and measuring interpersonal
continuity of care. Ann Fam Med 2003;1:134 – 43.

110. Bazemore A, Petterson S, Peterson LE, Phillips
RL. More comprehensive care among family phy-
sicians is associated with lower costs and fewer
hospitalizations. Ann Fam Med 2015;13:206 –13.

111. Lowe RA, Localio AR, Schwarz DF, et al. Associ-
ation between primary care practice characteristics
and emergency department use in a Medicaid man-
aged care organization. Med Care 2005;43, 792–
800.

112. O’Malley AS, Rich EC, Maccarone A, DesRoches
CM, Reid RJ. Disentangling the linkage of primary
care features to patient outcomes: a review of cur-
rent literature, data sources, and measurement
needs. J Gen Intern Med 2015;30:576 – 85.

113. Stange KC, Nutting PA, Miller WL, et al. Defining
and measuring the patient-centered medical home.
J Gen Intern Med 2010;25:601–12.

114. Anderson KM, Marsh CA, Flemming AC, Isenstein
H, Reynolds J. Quality measurement enabled by
health IT: overview, possibilities, and challenges.
Rockville (MD): Agency for Healthcare Research
and Quality; 2012.

115. Berenson RA, Pronovost PJ, Krumholz HM.
Achieving the potential of health care performance
measures. Princeton (NJ): Robert Wood Johnson
Foundation; 2013.

604 JABFM July–August 2018 Vol. 31 No. 4 http://www.jabfm.org

https://www.aafp.org/dam/AAFP/documents/advocacy/payment/apms/PR-PTAC-APC-APM-41417

https://innovation.cms.gov/initiatives/ahcm/

http://www.jabfm.org/

RESEARCH Open Access

Workforce planning and development in
times of delivery system transformation
Patricia Pittman1* and Ellen Scully-Russ2

Abstract

Background

: As implementation of the US Affordable Care Act (ACA) advances, many domestic health systems are
considering major changes in how the healthcare workforce is organized. The purpose of this study is to explore
the dynamic processes and interactions by which workforce planning and development (WFPD) is evolving in this
new environment.

Methods

: Informed by the theory of loosely coupled systems (LCS), we use a case study design to examine how
workforce changes are being managed in Kaiser Permanente and Montefiore Health System. We conducted site
visits with in-depth interviews with 8 to 10 stakeholders in each organization.

Results

: Both systems demonstrate a concern for the impact of change on their workforce and have made
commitments to avoid outsourcing and layoffs. Central workforce planning mechanisms have been replaced
with strategies to integrate various stakeholders and units in alignment with strategic growth plans. Features
of this new approach include early and continuous engagement of labor in innovation; the development of
intermediary sense-making structures to garner resources, facilitate plans, and build consensus; and a whole system
perspective, rather than a focus on single professions. We also identify seven principles underlying the WFPD processes
in these two cases that can aid in development of a new and more adaptive workforce strategy in healthcare.

Conclusions

: Since passage of the ACA, healthcare systems are becoming larger and more complex. Insights from
these case studies suggest that while organizational history and structure determined different areas of emphasis, our
results indicate that large-scale system transformations in healthcare can be managed in ways that enhance the skills
and capacities of the workforce. Our findings merit attention, not just by healthcare administrators and union leaders,
but by policymakers and scholars interested in making WFPD policies at a state and national level more responsive.

Keywords: Workforce planning and development, Human resources in health, Healthcare delivery reform, System
change, Loosely coupled systems, Labor-management partnerships, US Affordable Care Act

Background
As the implementation of the 2010 Affordable Care Act
(ACA) advances in the United States, many healthcare
organizations are taking bold measures to reorganize
their delivery systems and finding that in order to do so,
changes must be made to the healthcare workforce [1].
While different healthcare organizations in the United
States, be they public or private, are at very different
points in this process, commonly popular concepts in-
clude moving staff to new ambulatory and home care

settings [2]; creating new jobs relating to care coordin-
ation and outreach to the sickest patients [3]; designing
new modes of delivering care in response to consumer-
ism [4]; adopting team-based care and task shifting
based on the principal of practicing at the top of license
and education [5]; requiring new roles and skills as part
of the adoption of health information technologies
(HIT); and the use of data for decision-making [6].
Understanding what workforce changes are occur-

ring and how they are being managed is key not just
for healthcare leaders but for policymakers as well.
Traditional methods of projecting provider shortages
and justifying the allocation of public funding to
expand various professional pipelines are giving way

* Correspondence: ppittman@gwu.edu
1Milken Institute School of Public Health, The George Washington University,
2175 K Street, NW, Suite 500, Washington, DC 20037, United States of
America
Full list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56
DOI 10.1186/s12960-016-0154-3

http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-016-0154-3&domain=pdf

mailto:ppittman@gwu.edu

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

to the notion that there are many models of care delivery
and that they have vastly different staffing configurations.
For example, several studies have demonstrated that
including advanced practitioners in primary care medical
homes allows practices to expand panel sizes [7, 8].
Choices about staffing, therefore, can have enormous im-
plications for productivity, making assumption about the
demand for certain health professions a moving target.
The policy question then becomes not just how will

these changes alter the national demand for certain
types of health workers at an aggregate level but how
are organizations making choices about ways to recon-
figure their workforce and, ultimately, what kinds of
local, state, and federal policies are most supportive of
workforce transformations that advance both workers’
well-being and the value of their services.
We know from the literature reviewing the hospital re-

structuring of the 1990s that workforce change manage-
ment faces many challenges. The critiques of this era
were many, but chief among them, according to Walston
and colleagues, were the following: goals for change
were not clear, too many changes were implemented too
quickly, there was a lack of communication with em-
ployees, a lack of engagement with physicians and
unions, there was a poor understanding of the local
site differences by management leading to a one-size-
fits-all approach, and, lastly, that training needs were
not anticipated [9].
In a review of the international literature on workforce

planning and development (WFPD), Curson and col-
leagues suggest that the problem goes deeper. They
argue that workforce policies lack the capacity to re-
spond to new demands for system change [10]. The
reason, they point out, is that most workforce planning
do not take account of political dynamics among the
range of stakeholders outside the control of human re-
source administrators, be they at the organizational or
the policy level.
It is with these critiques in mind that we are interested

in understanding how two leading health systems in the
United States, with a historic commitment to developing
and retaining their workforce and to managing change
through labor-management partnerships, are responding
to the demands of the post-ACA environment. The aim
is to explore how they are determining what changes are
needed and how they are implementing those changes in
practice. Their experiences may provide insights for
other organizations, as well as for policymakers charged
with ensuring that the healthcare workforce is able to
meet population needs.
Our first case focuses on Kaiser Permanente (KP), an

integrated system that has historically served the em-
ployer market on the West Coast. It has been at the
forefront of systems that emphasize value over volume

and among the organizations most advanced in the use
of HIT to improve the patient care process. In addition,
KP has one of the most successful models of labor-
management partnerships (LMP) in the nation.
The second system is the Montefiore Health System,

headquartered in the Bronx, NY, an organization with al-
most 20 years of experience with shared risk contracts
with payers. Like KP, they have extensive experience with
care coordination, they are in the process of expanding
to new markets, and they have a LMP. They differ from
KP in that their patient population is predominantly
poor and Spanish speaking, and an extraordinary 80 %
of their revenue is coming from Medicaid and Medicare.

Conceptual framework
The objective of this study is to go beyond descriptive
groupings of health workforce changes to explore the dy-
namic processes and interactions by which staffing models
emerge. To frame our inquiry, we draw on the literature
on health workforce planning and development and the
theory of loosely coupled systems (LCS) [11].
For the purposes of this paper, we define WFPD as the

macro level processes and practices that enable the sys-
tem to change and adopt new staffing arrangements and
respond with timely and appropriate education, training,
and certification programs. Schrock has suggested that
WFPD policies span the continuum of skill formation,
employment networks, and career advancement [12].
This means not simply examining the supply and distribu-
tion of personnel in different categories but also under-
standing educational and training pathways, management
of performance, and the regulation of working conditions.
Dussault and Dubois argue that the traditional ap-

proach to WFPD is a linear, sequential, and protracted
skill formation process through which healthcare pro-
viders hand off demand projections to education institu-
tions and certifying bodies that in turn, supply the
requisite workforce [13]. Weick reasons that this form of
sequential task interdependence induces rule-based
action and cognitive processes that are not equipped to
tackle ambiguous problems like providing a skilled
workforce for care models that are in a constant state of
flux [14]. This and other complex, non-routine problems
require controlled cognition or slow, deliberative, and
explicit thinking that is more often associated with
reciprocal interdependence coordinated by an iterative
process of negotiation and mutual adjustment among
relatively autonomous units and subsystems. [14]
Dussault and Dubois describe an alternative approach

that is emerging in healthcare that coordinates the
efforts of a diverse range of institutional actors through
adaptive processes that respond to specific, local polit-
ical, economic, cultural, and social contexts where
healthcare is delivered [13]. This approach is understood

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 2 of 15

as a political exercise in which values and differences are
made explicit, compromises are made, and actions are
justified. Orton and Weick further suggest that there is a
need to move beyond the traditional focus on static
organizational elements, like structure, resource alloca-
tion, and technology, and turn instead to a focus on the
dynamic relationship among them [15].
Organizational scholars developed the concept of

“loose and tight coupling” as one way to examine com-
plex organizational structures and relationships [16–19].
The focus of this approach is on hierarchy and inter-
dependence among elements within and between organi-
zations and how variability in these features enables
different operational strategies and responses to shifts in
the external environment [17]. In tightly coupled sys-
tems, individual units and organizations are linked to-
gether through formal structures and procedures and
they respond to change through centralized control
mechanisms that reduce variation and close the system
off from the effects of external forces. In loosely coupled
systems, on the other hand, the links among the compo-
nents are weak and a high level of autonomy exists
among the interdependent parts of the system [20].
While the variation in the way similar functions are or-
ganized and managed may make it difficult to integrate
activities, theorists argue that it enables flexibility and
openness to change in the environment [15].
According to the theory of LCS, all systems are both

tightly and loosely coupled because there is variation in
how subunits are linked and rely on each other (couple-
d)—as well as in the number and strength of their con-
nections (lose or tight) [15, 17, 21]. Therefore, any
subsystem may be closed to outside forces to ensure for
stability (tight), while another subsystem may remain
open to outside forces to enable flexibility (loose) [15].
This paradoxical nature of LCS makes it difficult for

researchers to conceptualize and study [16], yet we
would suggest that its application to the US healthcare
system during this period of intense transformation
holds explanatory potential. Healthcare systems are sim-
ultaneously being asked to expand coverage and access,
while being financially incentivized to extend the con-
tinuum of care to address the social determinants and
provide ongoing care management. As a result, there
are significant pressures on traditional care models and
staffing arrangements, leading in turn to the emer-
gences of new patterns of “coupling,” both within and
across healthcare organizations. Further, we submit that
the effectiveness of the transformation occurring in
healthcare today may hinge on new, more adaptive
methods to prepare the healthcare workforce to
perform in a more complex system of care, where job
tasks, team interactions, and work locations are con-
tinuously changing.

To analyze changes in WFPD, we borrow from Weick’s
typology of strategies for changing LCS [11] and from the
descriptions on a new approach to WFPD in healthcare
put forth by Curson et al. [10] and Dussault and Dubois
[13] to identify a set of principles that together, may serve
as a new adaptive WFPD framework aligned with the
needs of a rapidly changing deliver system.

Methods
We use a case study design to explore how two major
health systems undergoing significant system transform-
ation are managing the process of workforce change. We
selected Kaiser Permanente (KP) and Montefiore because
they are well known for their innovative approaches to in-
tegrating healthcare yet they are significantly different
from each other with regard to their organizational histor-
ies, structures, and patient populations.
We conducted site visits to both organizations in the

spring and summer of 2015, conducting interviews with
8–10 people at each site including executives, human re-
source managers, the heads of innovation and care coord-
ination programs, and union and LMP representatives.
Some interviews were held in group settings, while others
were individual. We also conducted planning and follow-
up phone calls with some of the participants. Interviews
were taped and transcribed. We also reviewed current
organizational documents, including training plans, re-
ports, and collective bargaining agreements, as well as
prior studies on each system [9, 22, 23].
Data analysis proceeded through several steps. First,

the research team conducted a review of each case,
including the historic development of the system and
significant drivers of change, as well as the strategies,
structures, and resources informants reported as being
central to the competiveness of the system and the
sustainability of the workforce in the post-ACA environ-
ment. To support this analysis, the research team devel-
oped a series of inductive and deductive codes, which
we used to extract relevant data from the case docu-
ments and interview transcripts. Next, the researchers
jointly analyzed the coded data to developed individual
case profiles. These profiles were validated by key infor-
mants from each case. Finally, we conducted a constant
comparative method to identify cross-cutting themes
and principles to explain the workforce planning and de-
velopment strategy emerging within the two systems.

Results
Case study 1: Kaiser Permanente
Kaiser Permanente (KP) was established in 1938 as a
comprehensive medical system for the workers and their
families at Kaiser steel mills and shipbuilding facilities
across California and in Portland, OR. In 1945, after
WWII ended and many shipyards closed, KP opened

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 3 of 15

membership to the general public. The KP unions played
an instrumental role in this expansion by helping KP
market to unionized employers in areas where the com-
pany had a presence. Today, it operates as a Health
Maintenance Organization (HMO) with 8.3 million
health plan members in seven regions: Northern and
Southern California, Colorado, Georgia, Hawaii, Mid-
Atlantic, and the Northwest. Each region is made up of
two separate entities, the Kaiser Foundation Health Plans
and the Permanente Medical Group (PMG), a physician-
owned corporation that owns and operates KP’s medical
facilities. The PMG contracts with the Foundation to
serve KP health plan members. A key feature in this
model is that physicians are employed by KP. The na-
tional program office includes a variety of support func-
tions, including human resources, labor relations,
information technologies (IT), finance, and patient care
services (nursing).
The KP Labor-Management Partnership (LMP) was

formed in 1997. At the time, KP faced competitive
pressures leading executives to demand deep union
concessions. In response, many of the KP unions of-
fered the company a choice: continued harsh labor-
saving tactics and escalating labor strife, including a
strike, or a partnership to address the fiscal crisis and
improve the quality of care at KP. The company
agreed to the partnership [24]. The governance struc-
ture consists of the LMP Strategy Group, with one
representative from each of three sectors: Physicians,
Management and Labor, and each region maintains
its own tripartite LMP council.
By 2015, the LMP included 12 international and 28

local unions representing 105 000 KP employees or
about half of the total KP workforce, across six of the
seven regions. Hawaii is not part of the partnership, and
not all KP unions are involved in the partnership, most
notably absent is the California Nurses Association.
KP also has a network of functional units to support

the design and management of change and WFPD
strategies. The LMP staff is integrated into these units,
and labor representatives are highly engaged in their
activities. These units include the following:

� National Workforce Planning and Development
(housed in national human resources (HR))
provides opportunities to the KP workforce to
optimize skills and competencies and manages two
LMP education trusts: the Ben Hudnall Memorial
Trust and SEIU/UHW Joint Employer Education
Fund.

� National Innovations Network including patient care
services, workforce planning, and IT functions as a
loosely coupled “future-sensing” group that
examines technology trends, creates proof of

concepts and proof of technology, and develops
pilots.

� Unit-based teams (UBT) are natural work groups of
frontline workers, physicians, and managers who
solve problems and enhance quality.

Drivers of change
KP’s history of pre-paid, member-based service is critical
to understanding the company’s current competitive
situation. KP is well positioned to grow in a post-ACA
era in which policies to advance integration has prolifer-
ated. Growth has been especially dramatic in the South-
ern California Region, where new individuals that joined
via the Health Exchange grew by 4 % per year (from 2 to
6 %). This rapid influx of new members has been most
pronounced among younger and healthier individuals as
compared to members in KP’s traditional employer-
based plans.
KP leadership knew that they needed to understand

the implications of this shift in demand and have held
focus groups with their newest members. Results have
led the company to reorient business strategy around
three priorities, as follows:

1. Convenience. Millennials are demanding “care
anywhere and how we want it.” Increased access,
convenience, and enhanced experience of healthcare
are therefore major priorities for the organizations.

2. Affordability. Because the individual market is more
price sensitive than the group market, there is a
heightened awareness that they must reduce the
cost of care in order to continue to expand in this
market.

3. Value. At the same time, new healthcare consumers
expect more value or increased and enhanced
services, and this is driving a number of efforts
focused on the care experience.

Change strategies
Three strategic initiatives have emerged in response to
these drivers. The LMP and the national innovation
units are integrated into all three, as are KP members’
views, as represented through surveys, focus groups, and
ethnographic studies.

� Perform, Grow, Lead is KP’s strategic plan. It
emphasizes affordability targets, meeting rising
customer expectations, and transforming care.
Guiding principles include the following: One KP,
which calls for a common care experience across all
regions, and the KP people strategy, which
articulates the desired characteristics of the KP
workforce as “innovative, engaged, change ready,
healthy, and accountable.”

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 4 of 15

� Vision 2025 is an ongoing initiative to understand
what healthcare consumers will look like and how
KP can position itself to meet needs in a rapidly
changing healthcare market. It develops care models
and offers strategic road maps to guide planning and
change. Health information technologies are central
to this strategy, including the use of social media to
keep its members informed and healthy and new
mobile technologies to enhance staff communication
and reporting. Remote diagnostic tools will also be
more available to patients for common ailments like
strep throat, to allow self-testing and more rapid
recoveries. In the next 5 to 7 years, they see
increased use of remote monitoring technology,
sensors, and virtual care, as well as health analytics
to enhance the nurse role in triage and care
management [23]. As one interviewee put it, “…if it
can be automated, it will be.”

� Reimagining Ambulatory Design (RAD) is an
initiative of the Southern California Region that may
spread across KP. Its goal is to design a new
ambulatory care delivery model aligned to the
principles of consumerism. In extensive research
with members, the leads of this effort discovered
that “…people wanted access to care in a much
more radically different way… It has to do with
much more embedding of services into the
community, into the home, into work…and much
more local access for simple things.” This “life-
integration vision” has sparked several experiments
to redesign and relocate KP clinical operations in
Southern California.

Workforce planning and development strategies
Human resource (HR) leaders and the Coalition of
Kaiser Permanente Unions (CKPU) staff report that early
on the focus of WFPD was on creating consistent work-
force metrics and analytics to help the regions forecast
future staff and skill needs. They now view these tools
as necessary but insufficient. A regional HR leader
described the change:

So, at first…we forecasted membership growth,
utilization, supply, turnover, retirement, we looked at
the local labor markets, we connected with a
university for economic analysis of the projected
nursing workforce, and the fluctuations around the
economy. And then we realized that most forecasting
is based on the previous year, or the previous three, or
the previous five years, projecting forward. But if
you’re in the midst of complete transformation of
how you’re providing care, how accurate are those
numbers? …We need to understand what kinds of
jobs (are coming); we need to understand how work is

transforming. So, it really started in 2012 to 2013, (we
have been) trying to get a movement towards a kind
of qualitative approach to understanding change.

Key to this new approach is that it is integrated with
KP’s strategic growth initiatives. As one HR leader ex-
plained, “workforce development is being driven by the
business need.” Part of this emanates from the “affordabil-
ity” imperative, which both HR and labor representatives
agree has given finance a larger role in the company. At
the same time, HR leaders describe the emerging WFPD
approach as “maturing,” by which they mean that finance
is one important player but that they also take into ac-
count other interests. Indeed, HR leaders view themselves
as “intermediaries” who help senior leaders understand
the strategic value of the workforce in the context of the
drive toward labor-cost-saving solutions.
The LMP, which was further strengthened in the 2015

National Agreement, has several mechanisms that inte-
grate labor and innovative WFPD strategies into the
strategic change processes. First, for collective bargain-
ing, they use an “interest-based approach,” rather than
traditional, positional bargaining. Both sides emphasize
that there is full transparency in this process—manage-
ment shares information on the company’s financial situ-
ation, competitive standing, and other data related to
the subjects of bargaining and labor provides insight into
the affect of change on the workforce. This open ex-
change results in accommodation, as illustrated by the
Employment and Income Security Agreement (EISA),
which stipulates that any innovation or change at KP
must include a plan for retaining the effected employees.
A second LMP mechanism consists of the negotiated

programs to support innovation and the implication of
change for the workforce. The national agreement delin-
eates the mission and values of joint programs, sets aside
funds, and directs LMP staff and company to consist-
ently integrate the programs across all KP regions.
Examples of these national efforts include Total Health,
which advances wellness, health, and safety in the work-
place; unit-based teams, which identify quality improve-
ment and cost containment solutions at the ground
level; and the National Taft-Hartley Education and
Training Trusts, described above.
Lastly, an important characteristic of the LMP govern-

ance and planning structures is that it is holistic and aims
to permeate every level of the system. In theory, every
manager has a designated labor partner with whom they
are encouraged to engage in strategic and operational de-
cisions that affect the workforce. Both sides report that
this works better in some regions than others, but where
it does work, they say that the engagement is ongoing and
includes strategic decisions that affect not only the work-
force but also the future direction of the company.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 5 of 15

Jobs for the Future, an initiative in the Southern
California region, illustrates how these mechanisms
work together to integrate labor and WFPD strategies
into the strategic change processes at KP. The project
grew from the HR leader’s intermediary strategy of
showing up and intently listening at meetings related to
the RAD project, a strategic change initiative aimed at
redesigning ambulatory care. According to this leader,
he quickly convinced the VP overseeing the project of
the value of labors’ early involvement, and soon after, a
LM committee was formed to explore the proposed
innovation and its impact on the jobs and workers.
Rather than focus on the contentious questions of

workforce impacts, the committee first set out to de-
velop a holistic view of the redesign (new care models,
technologies, facilities, etc.) in order to target the oper-
ational initiatives that would have significant impact on
jobs. Though the HR lead reported that some labor and
management participants fell into traditional roles and
knee-jerk reactions, he observed that these positions
quickly gave way as the committee became more en-
gaged in the processes to redesign the care models and
workflows.
Next, the committee developed a rigorous method-

ology to assess the impact on jobs and formed LM sub-
committees to apply the method to the redesign of
specific work areas. In the end, the committee proposed
three new jobs: a roving receptionist of the future that
would take on multiple roles of patient greeter/way
finder/educator, a multifunctional healthcare worker that
would staff new small walk in clinics and perform patent
care and diagnostic functions, and a patient navigator
who would facilitate the extension of care into the arena
of social determinants by helping to coordinate commu-
nity resources. Each of these new roles transgresses
existing occupational, as well union boundaries and
jurisdictions.
The difference between the new with the old approach

to labor relations managing change at KP are explained
by the HR leader as he reflected on this project:

The traditional way of doing it is you’re assigning
labor relations people who don’t understand the
operations and all the technology and innovations.
They’re not included in those conversations. So they
go to the bargaining table, and the labor person has
only been told that there is either going to be a layoff,
or a change in jobs, and we are doing this because of
the need for affordability, or because we need to cater
to the customer. They are like, what!!??? So it is just
kind of set up for an antagonistic type of
relationship…because there hasn’t been this pre-work,
conversations and joint learnings about why this
change is really happening, how it will improve care.

There is a big disconnect between the innovators
planning this change and the bargaining with unions
to implement downstream workforce implications.

Interestingly, a union representative also sees her
role as an intermediary in the broader change pro-
cesses at KP:

What I’m trying to do is to help facilitate the
conversation. It’s really hard to make management
own what they want… What classifications do you
need? Where are you going to lay-off people? And
where do you want to grow, right? Put it on the table,
take the consequences…. And you will get (union)
members that say, I am not changing… Kaiser has a
lot of money; they do not need to do this… And
they’re wrong, but they are human; they are afraid.
(So I say) basically you’re stuck: either you learn this,
or you won’t have a job… So, that’s the conversation
I’m trying to facilitate. I try to get everyone to put
their issues on the table and work it out…

Challenges
While there are many success stories in the transform-
ation of WFPD at KP, informants also expressed concerns.
Several informants talked about the continued resist-

ance of some business units and regional operations to
the new WFPD approach. As one person explained, “the
C-Suite is on board with a human capital strategy and
there is a fair amount of engagement of line employees
in unit-based teams, but the middle management is not
fully engaged”.
While informants view the LMP as a powerful mech-

anism for managing the impacts of change, involving
workers who are represented by unions outside the LMP
and the large number of exempt employees in KP (al-
most half of the workforce) is challenging. As one in-
formant put it, “So what is the governance for this work
with the other half? Who sets the priorities, allocates the
resources, and oversees the initiatives?”
The fluid fiscal environment and constant innovation

are expanding the role of finance in strategic change and
workforce decisions. Informants did not challenge the
need for more fiscal control; their concern was over the
episodic nature and the short-term time horizon of the
financial decision-making process. As one person put it,
“it does not matter if the company and the LMP have
invested in a long-term strategy to fill a skills gap, fi-
nance can insist on a last minute reduction in force or a
redeployment to meet fiscal targets.”
Several informants expressed the need to figure out how

to bring workforce initiatives to scale and spread innova-
tions, like the Jobs of the Future, to other regions. They
believe that a deeper understanding of the knowledge,

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 6 of 15

skills, and methods that underlie the emerging WFPD
model might help spread innovation in KP.

Case study 2: Montefiore Health System
The Montefiore Health System is headquartered in the
Bronx, NY, and currently covers approximately 350 000
lives through a variety of value-based reimbursement re-
lationships with commercial and government payers.
Over 80 % of Montefiore’s revenue is derived from the
Medicare and Medicaid programs. Its leaders describe it
as an “open ecosystem” with long-standing partnerships
with the community, its labor unions, community-based
organizations (CBO), and local high schools and com-
munity colleges. This, we shall see, is a critical character-
istic of Montefiore’s approach to workforce changes.
The organization has a long history of seeking out

capitation and other forms of risk-sharing agreements.
Twenty years ago, Montefiore executives formed an
Integrated Provider Association (IPA), which encompassed
its salaried physicians, as well as community-based, volun-
tary (private-practice) physicians, and approached private
payers with a request to develop risk-sharing contracts.
While Montefiore experienced some losses during the
early days of managing these agreements, they pushed
ahead, understanding that the change would take time and
that returns would be realized only when there were higher
volumes of covered lives. The passage of the ACA, and in
particular the launching of Medicare’s Pioneer Accountable
Care Organization (ACO) program, in which Montefiore
was selected to be one of the original participants, opened
new opportunities for value-based contracts.
From the beginning, this active pursuit of value-based

contracts has been supported by a subsidiary called a Care
Management Organization (CMO), which developed a ro-
bust care management infrastructure with the explicit ob-
jective of understanding and addressing the upstream
determinants of health. The CMO’s approach to care co-
ordination includes health education, linkages with social
services and government benefits, health system navigation,
provider communication, chronic care management and
care transition management, and medication review and
reconciliation. A focus on patients with high medical ex-
pense and high risk of hospital and emergency department
utilization by interdisciplinary care management teams has
generated savings that that are reinvested in the delivery
system. Care coordination is extended beyond Montefiore’s
facilities through active partnerships with community-
based, voluntary physicians as well as a wide range of com-
munity service organizations.
The CMO supports this care model with a robust

WFPD infrastructure that includes a comprehensive
competency map for all key CMO workflows supported
by a wide range of training programs to ensure em-
ployees are prepared with the required skills.

In addition to the CMO WFPD capabilities, Montefiore
Human Resources (HR) and Labor and Employee
Relations functions have structures and mechanisms to
integrate HR as well as labor into unit-based change. For
example, HR stations a HR person in every department
whose role is to understand the local culture and help HR
anticipate and support change. This sensing function also
enables HR to ensure the engagement of labor in planned
changes.
Regionally, Montefiore also has a long history of labor-

management partnership through its participation and
leadership in the 1199SEIU Training and Employment
Fund. The fund, which was established in 1969 to pro-
vide education and job training programs for healthcare
workers, is the largest joint labor-management training
organization in the United States. It covers 250 000
workers (190 000 in New York City) and more than 600
employers, including hospitals, nursing homes, regis-
tered nurses (RN), and home care workers. 1199SEIU
and healthcare employers jointly govern the fund and
Montefiore’s Executive Vice President is on the Board of
Trustees.
Since its formation in 1969, 1199SEIU has established

a total of nine funded initiatives, of which Montefiore
contributes to five, that cover three main areas:

� Training and upgrading: There are two training and
upgrading funds (one specific to RN and one
general) that work with Montefiore and union
leaders to identify high-demand skills and
occupations and develop training programs in
response. It includes counseling and tutoring, adult
basic education and pre-college preparation
programs, and an array of college education benefits
to support workers in attaining college degrees in
healthcare-related occupations.

� Job security: An additional fund provides a safety net
and rapid re-employment services for laid-off
workers, who receive priority employment from
hundreds of healthcare institutions in the NYC area.
They also support job counseling, placement,
training programs, and benefits to assist workers’
transition into a new job in healthcare.

� Labor-management initiatives: This fund seeks to
increase worker voice in the planning and
implementation of efforts to increase quality care,
patient satisfaction, and operational effectiveness. It
supports technical assistance on the development of
joint governing structures and training in joint
problem solving around quality and performance
issues.

The funds are financed by collective bargaining contri-
butions, with employers contributing 0.5 % of gross

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 7 of 15

payroll to the Training and Upgrading Fund and smaller
amounts to the other funds. The funds have also re-
ceived over $300 million in grants to open their pro-
grams to community members and other healthcare
workers who are not members of the 1199SEIU.

Drivers of change
The ACA’s payment reforms allowed Montefiore to le-
verage its experience with value-based purchasing and
deepen its commitment to population health. However,
New York state health policy, in particular the ambitious
Delivery System Reform Incentive Payment (DSRIP)
Program, a product of New York’s Medicaid Redesign
Team (MRT) Waiver Amendment, is likely the greatest
driver of change at Montefiore.
DSRIP will fundamentally restructure the healthcare

delivery system by reinvesting in the Medicaid program,
with the primary goal of reducing avoidable hospital use
by 25 % over 5 years. Up to $6.42 billion dollars are allo-
cated to this program with payouts based upon achiev-
ing predefined results in system transformation, clinical
management, and population health. The entities that
are responsible for creating and implementing DSRIP
are Performing Provider Systems (PPS). PPS are pro-
viders that form partnerships among major public hospi-
tals and safety net providers, with a designated lead
organization for the group. There are 25 PPS across the
state, with Montefiore leading one in the Hudson Valley
and participating in a second PPS in the Bronx (Bronx
Partners for Healthy Communities) led by St. Barnabas
Hospital (SBH).
A major focus of DSRIP is to develop strategies to re-

align, redeploy, and retrain the healthcare workforce
across the provider networks within broad regions
throughout the state. DSRIP has also merged the Office
of Mental Health, Office Alcoholism and Substance
Abuse, and Department of Health (DOH), so there is a
single regulatory structure with payment aligned. This
means all community-based organizations (CBO) will
begin to receive their funding from this single payer/
regulator at the state level. Montefiore executives de-
scribe the program as “right-sizing” Medicaid. All care
will be managed, and the number of contracts with
HMOs will be dramatically reduced from 17 to 7–10
plans. Ultimately, the program’s goal is to achieve 90 %
value-based payment in 5 years.

Change strategies
Over time, Montefiore’s leaders have realized that to make
their value-based contract model work, they needed to
create economies of scale. The strategy has so far resulted
in the outright acquisition or other partnership arrange-
ments with nine hospitals, several of which are in the
Hudson Valley, a region that is largely exurban, dominated

by solo practices, and radically different from the Bronx in
terms of patient demographics. In addition, Montefiore
views its engagement in DSRIP as an opportunity to ex-
pand its model to a broader continuum of care in the
Bronx as well as in the Hudson Valley. Finally, it has
begun to expand into new lines of business with the estab-
lishment of the Managed Long Term Care Plan (MLTCP),
which may transform Montefiore into a fully integrated
delivery system. The implication of these expansions is
significant, both for the workforce and more broadly in
terms of testing the feasibility of Montefiore’s population
health model in new environments.

Workforce planning and development strategies
The central workforce dynamic resulting from the
DSRIP rollout and Montefiore’s policy of acquisitions is
that Montefiore is rapidly blurring its traditional work-
force boundaries. This has multiple implications for its
approach to WFPD. First, the inclusion of new facilities
and regions requires HR to integrate the workforce into
Montefiore’s culture, often in the context of downsizing
and redeployment of staff. Second, the merging of the
various social service payment schemes into one payer/
regulator under DSRIP will mean that Montefiore has a
direct financial interest in strengthening CBO services
and, therefore, the capabilities of its workforce. Third,
early discussions among partners in the PPS suggest a
commitment to relocate any displaced workers from
partner organizations in the PPS to avoid unemploy-
ment. This will not only intensify the imperative to ex-
pand care coordination across providers and CBO, but
now extend WFPD outside the traditional boundaries of
Montefiore’s employees. An HR leader described the
change:

Whereas in years past we focused on our own
employees and attracting top talent, now we are (also)
interested in folks in the community and their future,
and how to get them interested in a health care
profession…We are partnering with schools, and
building health care curriculums…And we have a
greater focus on development and education of our
community partners. We are doing more with
internships and externships and volunteerism…It’s
really about building the health of the community.

Montefiore’s WFPD strategies are emerging within
three loosely coupled and well-resourced efforts: expan-
sion of the CMO’s competency and training map, lever-
aging regional ties through its LMP, and embracing
DSRIP aims to build a strong provider network. Each is
closely tied to Montefiore’s strategy to build economies
of scale and improve population health.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 8 of 15

The first strategy involves the expansion of the CMO
comprehensive training program to support Montefiore’s
efforts to bring its care management model to scale. A
core feature of this effort is a competency map that
specifies what each worker needs to know and do
and identifies curriculum pathways for each of the 80
clinical and non-clinical roles in the CMO. One in-
formant shared that the map enables the CMO to
scale up training and target delivery throughout the
growing continuum of care.

It’s not scalable to create an education program that
trains every single person here on how to arrange
transportation or how to find a pharmacy that
delivers. We want that to be role specific and matched
to the right skill set so the training that goes with
each role is then matched to what we expect people
in that role to do… If we hadn’t gone to a model like
that, it’s just not scalable.

The CMO model has both loose and tight elements.
The loose characteristics include the placement of facili-
tators in the CMO units to listen and support people in
developing the skills and knowledge required to continu-
ously improve the model. There is also an educational
council comprised of representatives from throughout
the system that helps ensure frontline input into learn-
ing needs and evaluation of training programs. Its tight-
ening mechanisms include standardizing some elements
of training to help spread the care coordination model
to the new Montefiore and the PPS partners.
The second WFPD strategy involves leveraging

Montefiore’s affiliation with the 1199SEIU League Train-
ing Fund to intervene into the regional healthcare labor
market to address broad workforce challenges facing the
industry as a whole. For example, Montefiore, in partner-
ship the Training and Upgrading Fund, agreed to provide
a clinical site for a RN-to-BSN bridge program being of-
fered by the City University’s Lehman College in the
Bronx. This partnership brought to light Montefiore’s con-
cerns about nursing school curricula, which are largely fo-
cused on training nurses for acute care roles and lack
preparation around care coordination and population
health. The partners addressed this gap in this one-time
bridge program with the inclusion of a care management
module. Since then, the parties have worked together to
revamp the curricula to better prepare nurses for care
management and care coordination careers—which in-
clude courses on the broader institutional changes in
healthcare and changing care models. Montefiore and the
training fund’s involvement in two regional DSRIP PPS
will likely afford them an opportunity to replicate this kind
of partnership with other schools of nursing and programs
to train workers for other high-demand occupations.

On the internal front, though labor union relations
were described as being “very collaborative” and “very
well integrated into the facilities,” the degree to which
the LMP is involved in Montefiore’s innovation and
growth strategies is unclear. The nature of labor rela-
tions at Montefiore maybe best illustrated by the way in
which CMO managers described problems redefining
jobs and job titles. They essentially work hard to respect
the union, but efforts to engage unions in the redefin-
ition of jobs, as occurred in KP’s Southern California
region, have not taken place.

In the union contract you have certain titles and those
titles really still largely crosswalk to functions that you
would have seen in a hospital or maybe in a
physician’s office. But to get a new title is hard. It has
to be negotiated… So what we’ve tried to do is take
our functions and crosswalk them to existing titles.
Our titles don’t always completely (crosswalk to the
new duties)…It would be nice to have more flexibility,
because it takes too long (to negotiate change).

Despite these challenges, HR leaders described their
relationship with labor as being based on mutual trust
and collaboration. For example, Montefiore developed
training for hospital staff on Hospital-Acquired Condi-
tions for which CMS will no longer reimburse. They
partnered with 1199SEIU to roll out the program, which
they believe greatly facilitated workers’ confidence that
the program would be beneficial and not harmful to
their interests.
The third workforce strategy involves embracing the

DSRIP aims to build a strong provider network. With
reduction of potentially avoidable emergency room
(ER) visits and hospital admissions as end goals, the
NY DSRIP stipulates that an immediate task is to “re-
train the workforce for care continuum and redeploy
them to ambulatory and home care.” Executives
describe this challenge on several fronts. First, they
report “We work across health care settings and
CBO’s in the PPSs to standardize titles and compe-
tencies, and to establish criteria for determining how
care will be coordinated.” They point out that this
process is made particularly challenging by the vast
array of ways that organizations across the PPS
network have organized jobs. “Some organizations re-
quire care managers to be RNs, while others employ
individuals with … a high school diploma or a GED
as care managers. There is a lot of cross cutting
(comparison) that we need to do.”
CMO leaders say a key challenge is ensuring that its

standards are maintained as the number of organizations
involved in the continuum of care expands through the
DSRIP process.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 9 of 15

There are a myriad of organizations out there that
provide all kinds of services… peer groups, housing
groups, mental health, substance abuse, transportation…
They’re not going to be our employees… (but) we’re
going to have to make decisions about (whether) we are
comfortable actually turning over the responsibility for
case management in a particular case.

The second area of work required by DSRIP will be to
manage the relocation process. DSRIP anticipates that, over
time, hospitals will reduce the number of beds or close
shrink and that ambulatory-, home-, and community-based
care will grow. Workers will need to be retrained to move
into these new settings within PPS. The 1199SEIU League
Training and Employment Fund, which spans multiple em-
ployers, will likely play a role in managing these transitions
through its Job Security Fund.

Challenges
Despite what is largely a story of successful relationships,
Montefiore informants were frank about the challenges
ahead that concern them.
The first is a reflection of the need for continued mat-

uration of the labor partnership. In particular, the lack of
flexibility in renaming and redefining jobs has been an
impediment to change and expansion plans. “It would
be nice to have more flexibility.”
Another challenge is related to the design and use of

community health workers (CHW) across the new
DSRIP PPS networks. Currently, these jobs are different
in their design and function, based on where the work is
performed in a very broad spectrum of care coordin-
ation. Historic interests and political dynamics have in
part shaped these varied roles. There are deep differ-
ences over how to integrate CHW, e.g., whether they
should be hired directly into the organization, and of
course, there are divergent views on which union might
claim this growing cadre of workers. The question is
whether the CMO’s data-driven innovation strategy will
work in this highly politicalized context or whether new
consultative mechanisms are also needed to successfully
integrate diverse occupational roles and cultures.
The third challenge regards the spread of the model to

the Hudson Valley. Currently, Montefiore’s relationship
with its newly acquired facilities in the region is largely
financial—but ensuring institutional stability will require
Montefiore to transport its care coordination and
community-based approach. This model is in part reliant
on a large system that can move workers affected by
change in one facility to new roles and locations in the
expanding continuum of care. It remains to be seen
whether there are the workforce relationships and mech-
anisms that will facilitate such processes in this subur-
ban and exurban area of the state.

Discussion

Though KP and Montefiore are very different systems,
each mounting a different strategic response to the
ACA, they share a common understanding of the cen-
trality of the workforce in any delivery system change
process. This is reflected in a series of common themes
that emerged in relation to our central study questions:
how are these systems determining what changes are
needed, and how they are implementing change in prac-
tice? Below, we identify five broad themes present in
both systems and discuss in the context of the theory of
LCS. We then extrapolate the principles in each that
may be relevant to other health systems and to broader
issues of workforce policy and practice.

Core values and a centralized vision
The first theme common to these case studies is that
both organizations have a set of strong core values and a
centralized vision with regard to their goals. At KP, the
history of pre-paid, member-based service has instilled a
core value for health prevention, while its roots as an
innovator in the delivery of comprehensive medical
services to workers and their families contributed to
KP’s vision for continuous innovation and healthy work-
places. These values and vision appear to be one explan-
ation for KP’s extensive investment in the LMP and the
many LM programs aimed at improving working condi-
tions and making KP an employer of choice. Extensive
engagement of labor in change decisions, coupled with
the integration of innovation units into the change pro-
jects, helps to ensure that these values and vision are
key factors in determining the needed change in KP.
More recently, participation in the Health Exchanges
has led to the adoption of additional values centered on
the ideas of consumer convenience and affordability.
These new values are also informing the current cycle of
innovation and change in the company.
At Montefiore, the core value of population health not

only directs internal change, it underlies its efforts to
build extensive external partnerships aimed at improving
the entire continuum of care in the region. Regardless of
whether WFPD is focused on current employees or the
external pipeline of people who need jobs, Montefiore
informants view these investments as part and parcel of
a population health strategy. An HR leader summarized
the viewpoint: “…we believe [these external WFPD pro-
grams] are good for us as an organization.” In addition,
Montefiore’s centralized vision of socially oriented care
links and integrates many locally driven innovations and
care models to the overall system. “…Every facility [in
the Montefiore Health System] has its own culture, but
the core is… our vision and our values.” These values
and vision are embedded in the formal and informal
processes that drive care and change at Montefiore. “If

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 10 of 15

they (a newly acquired facility) are following the process,
the culture starts changing; there is no other way.”
Weick [11] and Burke [17] argue that large-scale, insti-

tutional change, like that occurring in healthcare today,
requires a high degree of cooperation that is difficult to
achieve among the many semi-autonomous subunits and
organizations in LCS. Burke suggests that shared values
help remind people why the system exists in the first
place, while a centralized vision contributes focus within
the dynamic complexity of LCS.
In both cases, we see that their historical and cultural

context is key to understanding how they integrate
WFPD activities into ongoing change processes. The
emerging principle, then, is that the situation determines
what type of adaptive WFPD is possible in the first place.
This means that WFPD is not just a technical exercise; it
must also appraise the political, economic, cultural, and
social dynamics within specific contexts in which health-
care takes place [13]. To be effective, the process must
consider the multiplicity of values that drive healthcare
and WFPD decisions [13].

Transparency and early dialogue
The second theme that emerged in both cases is the com-
mitment to transparency with regard to the goals and cri-
teria for making decisions about changes and to an early
dialogue with stakeholders, in particular labor, around the
best way to organize the change. In both systems, we see an
institutional commitment to early collaboration with labor
and other key partners throughout the change process.
In KP, the national agreement and the investment in

the LMP have resulted in a highly integrated system of
corporate governance that involves labor in strategic
decisions on every level of the company, from the UBT
to national strategic planning efforts. The sharing of
sensitive corporate information and performance data is
essential to making these efforts work.
The extent to which labor is involved in determining

internal change in Montefiore is unclear, though HR
leaders did talk about the importance of early dialogue
with labor about planned changes: “…we contact them
early so that they do not hear about things late.” Accord-
ing to an HR lead, this early consultation results in labor
buy-in, which in turn provides employees with the assur-
ances they need to engage in change.
Greater emphasis on transparency and early dialogue

between Montefiore and 1199SEIU, its largest union,
was observed in external efforts to close gaps in the
labor market and in their mutual engagement in the
DSRIP planning process. The expansion of the one-time
nurse bridge program to create a new curriculum to
prepare nurses for care coordination roles is an example
of how joint leadership resulted in improvements to the
WFPD infrastructure in the region.

The theory of LCS suggests that transparency and
early dialogue are highly functional change mechanisms,
because they open the process to many different inter-
ests and vantage points required for sense making [25].
In addition, these mechanisms create shared leadership,
which is more effective than hierarchical leadership
when seeking to tighten connections within a LCS [17].
An emerging principle then is that WFPD is integrated

with strategic and operational planning processes.
Beekun and Glick [16] define integration as a process for
achieving unity of effort among various subsystems in
the accomplishment of the organization’s tasks and
goals. Moreover, from a change perspective, efforts to in-
tegrate are seen as boundary defining and boundary
spanning, which is a political process that requires on-
going negotiation and mutual adjustment [17]. With
these concepts in mind, this principle suggests that
WFPD is a dynamic process of negotiation and mutual
adjustment among semi-autonomous subunits in a LCS
that seeks to integrate the workforce into the change
processes within firms, as well as, as we shall discuss
below, to align internal change with the system-wide
skill formation goals and activities of WFPD institutions.

Innovations to workflow
The third theme is changes often emanates from innova-
tions to workflow that emerge from an analysis at the
unit level and then take into account competing inter-
ests across the system. This is in contrast to change de-
fined based on existing jobs and organizational structure
or simply an analysis of who currently does what.
For example, KP’s UBT engage in the process on an

ongoing basis. In Southern California, efforts to mas-
sively revamp ambulatory care based on the principles of
consumerism began at a central level with a complete
rethink of consumers’ wants and then engaged stake-
holders in a discussion about how and where work is
carried out, as well as who does what.
The innovation model in Montefiore also starts with

an analysis of the optimum work design at the unit
level, as opposed to the current workflows and job
structures. The CMO competency map then uses the
local analysis to build a whole-system approach to
WFPD. It identifies the range of knowledge and skills
that are required for coordination across the con-
tinuum of care, and it delineates what every occupa-
tion group needs to know and do to support the care
model. This tool ensures that the required expertise
is available across the entire system, while it also en-
ables the customization of curriculum pathways for
each role and individual in the CMO.
There are several emerging principles here. The first

related once again to integration, as discussed above.
But in addition, we see principles of both a holistic

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 11 of 15

approach and an approach that is adaptive to chan-
ging demand.
The holistic principle implies the consideration of the

whole system of professions and occupations, as op-
posed to each profession having its own distinct role,
training structure, and regulatory mechanisms. Dussault
and Dubois posit that a traditional siloed approach in
healthcare hinders the implementation of policy and
complicates the change process, particularly when new,
multidisciplinary models that require a high degree of
interdependence among many different professions are
required [13].
A related principle is that adaptive WFPD must be

responsive to changing demand. Both systems have con-
cluded that the traditional linear approach to WFPD is
necessary but not sufficient. Their adaptive approaches
begin with a focus on the demand for healthcare and try
to account for the macro shifts and trends as well as the
internal political dynamics affecting the health system
and its workforce [13]. In the complex setting of health-
care today, this requires a highly participative decision
approach that accounts for many perspectives that is
also supported by accurate, robust, and accessible data
that can account for the large and growing number of
variables that affect the demand for care and the supply
of the workforce [10, 13]. New methods are also re-
quired that can utilize the new so-called big data systems
to model the efficacy of possible care models and WFPD
scenarios [10].

New patterns of coupling
The fourth theme is the new patterns of coupling, in-
cluding both tightening and loosening of the alignment
of each company’s component parts. These changes are
consistent with the proposition of Bechun and Glick,
who argue that institutional changes can set into motion
new patterns of coupling within organizations as they re-
spond to the changing environment. They also claim
that the strategies used to foster new patterns of coup-
ling will reflect the organizations’ traditional approach to
implementing change.
We have seen that, historically, KP grew as a loosely

coupled network of providers (Permanente Group) and
an insurer (Kaiser Foundation Health Plan), across seven
semi-autonomous regions. Recent efforts to streamline
administrative systems through “One KP,” as well as
HR’s work to create centralized skill standards and train-
ing, reflect an attempt to cut costs and to create a com-
mon corporate identity by tightening connections. In
addition, the influx of new individual members is pushing
KP to both loosen and realign their historic workflows
and communication patterns by relocating care and con-
solidating roles to improve care and make it more access-
ible. Lastly, we see how technology continues to play an

important role in meeting long-held objectives to tighten
the connection between KP and its members, as well as,
they hope, to improve the quality of care.
Similarly, Montefiore’s historic strategy to promote

value-based contracting led them to extend their care
model by tightening their connections throughout a
loosely coupled network of providers, and this approach
continues to grow as they expand into new regions.
Once connections are made, CMO takes the lead in
tightening efforts by identifying the parts of the system
where outcomes are weak and costs are high and then
turns the focus to the redesign of work, followed by
training, both initial and continuous. Now, with the
expansion of the system into new regions, and the new
relationships with external providers and community-
based organizations that are being formalized through
DSRIP, the CMO is poised to integrate its approach with
external partners.
The emerging principle here is again integration, not just

with regard to internal realignment but with external rela-
tionships as well. This is particularly striking in the case of
Montefiore, where their new patterns of integration are
aligning internal change with external partnerships.

Maturing the WFPD model through intermediary
functions
Both systems work hard to continuously mature their
approach to WFPD. Indeed, Burke anticipated that as
LCS grew more commonplace in business and society,
change agents would need deeper knowledge of the
dynamics of LCS and more complex change strategies to
enable both the tightening as well as the loosing of ties
throughout the system. Change agents know how to
tighten, according to Burke, but few can discern the
need to loosen and then effectively intervene.
Informants in both cases were quite articulate about

their WFPD model and the need to improve and expand
it beyond the traditional approach. Intermediary struc-
tures form the structural basis for the WFPD model in
both cases. Intermediaries, according to Giloth, broker
and integrate a variety of interests and resources to en-
act WFPD in local settings [26]. As seen in both cases,
these intermediaries devote a great amount of “face time
and linguistic work” to help people make sense of the
ambiguity brought about by the unpredictable structures
within LCS [25].
The intermediary partnership in KP is made up of a

loosely coupled network of staff housed in a variety
of support units who “show up” at important corpor-
ate innovation meetings and establish a presence in
the change process. In addition to showing up, infor-
mants talked about a variety of intermediary strat-
egies, such as aggressive engagement, deep listening,
and accommodation, that they utilize to help HR and

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 12 of 15

the LM to “translate the workforce and labor piece”
of the change. Thus, in KP, the intermediary strategies
provide a valuable sense-making function that help
the parties respond to change. One informant claimed
that this intermediary, sense-making approach “…is
core to how you transform workforce planning.”
Intermediary partnerships also provide sense-making

functions throughout Montefiore. The HR Business
Partners also show up at business meetings and they
link HR processes to change occurring in operational
units. The CMO’s Education Council and frontline fa-
cilitators are listening mechanisms that align training
with change occurring in the system. Lastly, in the
context of DSRIP, Montefiore participates in work-
force planning in the Bronx and the Hudson Valley
PPS. In the Hudson Valley, they are engaging provider
HR and operations staff in a preliminarily needs as-
sessment to help make sense of future staffing needs
and to identify gaps and resources. This was de-
scribed as an analytical process to develop a strategy
to close the gaps required to make each new role
successful.
A major emerging principle regarding this theme is

that decisions are being made through a process of
consensus building that includes workers and are ac-
commodative of the needs, interests, and preferences of
participating groups. Again, WFPD is both a political
and technical exercise [13], and as such, it calls for a
process of exchange, negotiation, and mutual adjust-
ment [11] among a diverse range of stakeholders.
Consensus is necessarily achieved through processes of
accommodation to the needs, interests, and preferences
of the client. According to Burke [17] change agents
must accept that they cannot fully understand and
appreciate the client’s deep situational knowledge and
approach each setting with curiosity. This openness
promotes learning and shared ownership of WFPD
problems, activities, and programs.
In addition, we see that WFPD is a process that is

continuous and iterative. Dussault and Dubois suggest
that the historic system of professional dominance in
healthcare calls for an ongoing process (continuous) of
adjustment (iterative design) that can attend to popula-
tion needs as well as the changing expectations and
roles of the healthcare workforce [13]. Further, Weick
and Burke suggest the ambiguous and complex inter-
relationships in LCS require an improvisational change
process that connects past experience and knowledge
(continuity) to present novelty through tinkering
(incremental change) [17, 27]. Achieving this approach
requires an eclectic mix of listening, practice, modeling,
the ability to recognize the partial relevance of previous
experience, and a high confidence in skill to deal with
non-routine events [11].

Finally, WFPD is generative, resulting in new resources
and capacity for innovation. We see in both cases that
WFPD requires institutional capacity and the investment
of time and money in sense making and structuring ac-
tivities [13]. Both cases demonstrate how the interest in
listening and accommodation has implications for inter-
mediary WFPD structures and resources. And resource
allocation for these functions is significant, in particu-
lar for the LMP at KP. Both organizations are also
recruiting top talent in workforce development and
place a high value on the expertise of their employees
in this area.

An emerging framework
The seven principles emerging from these case studies,
when considered synergistically, help provide a frame-
work for thinking about adaptive WFPD in specific con-
texts. Table 1 synthesizes our findings for this purpose.
This emerging framework is consistent with the theory

of LCS and resonate strongly with the critique offered
by Dussault and Dubois of human resource planning in
the healthcare sector. We would suggest that others
could adopt these propositions to think about WFPD in
new and innovative ways

Conclusions
This comparative case study analysis suggests that the
old way of doing WFPD by estimating the workforce
needs within the confines of an institutional setting is
giving way to new adaptive approaches. Institutional set-
tings in the context of a post-ACA landscape are simply
too complex and fast paced for the old approach to
work. Both KP and Montefiore understand that the only
way to do WFPD in periods of rapid transformation is
to engage—to listen and interpret what is happening
from a workforce perspective. This process requires

Table 1 Emerging themes and their related principles

Common themes in case studies Related theoretical principles

1. Strong core values and vision 1. Historically and culturally
situated

2. Transparency and early dialogue
with labor and other stakeholders

2. Integrated, internally and
externally, with strategic and
operational process

3. Innovations in workflow (2) Integrated
3. Changes are holistic
4. Changes are adaptive and
based on data about changing
demand

4. New patterns of coupling (2) Integrated

5. Maturing the WFPD model
through intermediary functions

5. A process on ongoing
consensus building

6. Continuous and iterative
7. Generative of new investment
in the function

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 13 of 15

developing an institutional capacity for sense making
[11] across the organization, achieved through a con-
tinuous process of engaging, listening, and organizing.
WFPD is therefore no longer a centralized function at

KP and Montefiore. Control mechanisms have been re-
placed with strategies to integrate various stakeholders
and units across a broad continuum of WFPD activities
and programs. The new approach to WFPD is aligned
with strategic growth plans and is integrated with labor,
employment relations, innovations teams, and local
change initiatives. Both systems demonstrate a concern
for the impact of change on their workforce and have
made large political as well as financial commitments to
avoid outsourcing and layoffs.
We find that a series of new change principles defined

by theorists as suitable for improving the functioning of
LCS [11, 17] and aligned with the adaptive WFPD model
[10, 13] are present in both organizations. The principles
include WFPD that is (1) situated in a set of core values
that have emerged from specific historic and cultural
contexts; (2) integrated, both internally and externally;
3) focused on a whole-system perspective; 4) responsive
to changing demand; 5) based on consensus building,
that is (6) continuous; and (7) generative and requires
real and continued investment.
The effective implementation of these principles in

these two major health systems has given rise to a pat-
tern of reciprocal interdependence and mutual adjust-
ment among the diverse range of actors across the
WFPD ecosystem. This new form of coordinating WFPD
across the system is both enabled by and helps to foster
a form of knowledge-based action and a pattern of
thinking that is slow, deliberate, and explicit—and is
more aligned with the complexity of health workforce
changes in a post-ACA environment.
These findings may be relevant to a range of other

healthcare organizations. While the payment reforms
that are spurring workforce transformations may be
different for public systems, like the Veterans Health
Administration in the United States, to the extent that
they are embracing any major system changes, these
WFPD principles would be applicable. In other words,
the principles are about managing change in complex
organizations, not about the specifics of the changes.
The findings may also hold meaning for macro-level

workforce policies at the state and federal governments.
Technocratic WFPD at these levels is also likely to be
insufficient during periods of large-scale system trans-
formation. Traditional policy levers, such as scope of
practice regulation, education and training curriculum
and degrees, and professional codes, have not been re-
sponsive to the needs of LCS, because they are designed
to ensure uniformity in roles and job structures across
the broader healthcare system.

If today, we are likely to see less uniformity in our dis-
tributed, free-market healthcare system as it continues
to innovate and multiply new models of care, then
WFPD at both the organizational and the public policy
levels must also go beyond data analysis and engage in a
political process of spanning traditional boundaries,
listening to diverse interests, and building consensus. It
requires new intermediary structures, and it must be
generative of new resources and new talent. It also re-
quires building the political and technical skills of
WFPD professionals and empowering them to challenge
old practices and ways of thinking about workforce
issues and problems [13] and address the structural and
financial gaps in the skills formation continuum.

Abbreviations
ACA: Affordable Care Act; ACO: Accountable Care Organization;
CBO: Community-based organizations; CHW: Community health workers;
CKPU: Coalition of Kaiser Permanente Unions; CMO: Care Management
Organization; DOH: Department of Health; DSRIP: Delivery System Reform
Incentive Payment Program; EISA: Employment and Income Security
Agreement; ER: Emergency room; HIT: Health information technologies;
HMO: Health Maintenance Organization; HR: Human resources;
IT: Information technologies; KP: Kaiser Permanente; LCS: Loosely coupled
systems; LMP: Labor-management partnerships; MRT Waiver
Amendment: Medicaid Redesign Team Waiver Amendment;
PMG: Permanente Medical Group; PPS: Performing Provider Systems;
RAD: Reimagining Ambulatory Design; RN: Registered nurse; UBT: Unit-based
teams; WFPD: Workforce planning and development

Acknowledgements

No applicable.

Funding

This article was supported by a cooperative agreement with the National
Center for Health Workforce Analysis, Health Resources and Services
Administration. The funder did not have a role in the design of the study
nor collection, analysis, and interpretation of the data or in writing the
manuscript.

Availability of data and materials

All interview recordings and notes are available upon request.

Authors’ contributions

Both authors made substantial contributions to conception and design,
acquisition of the data, and analysis and interpretation of the data. They
were both involved in drafting the manuscript and revising it and approving
the final version for publication.

Authors’ information

PP is the Director of the George Washington University Health Workforce
Research Center and the Co-Director of the George Washington University
Health Workforce Institute. PP teaches and focuses her research on health
workforce policy. Her recent focus is on workforce innovations in the context
of system change.
ES is a Professor of Human and Organizational Learning. She is an expert in
qualitative research methods and has more than 25 years of experience as a
workplace learning and workforce development practitioner in a wide range
of industries including healthcare, telecommunications, manufacturing,
hospitality, and the public sector. She has worked with dozens union-
management partnerships on the firm, regional, and industrial levels to
develop policies and programs to meet the dual goals of supporting
individual learning and development and improving industry and firm
performance.

Competing interests

The authors declare that they have no competing interests.

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 14 of 15

Consent for publication

Not applicable

Ethics approval and consent to participate

Not applicable

Author details

1Milken Institute School of Public Health, The George Washington University,
2175 K Street, NW, Suite 500, Washington, DC 20037, United States of
America. 2Graduate School of Education and Human Development, The
George Washington University, 2136 G Street, NW, Washington, DC 20052,
United States of America.

Received: 15 April 2016 Accepted: 12 September 2016

References

1. Pittman P, Forrest E. The changing roles of registered nurses in Pioneer

Accountable Care organizations. Nurs Outlook. 2015;63(5):554–65.
2. Vesely R. The great migration. Hospitals and Health Networks Web site.

http://www.hhnmag.com/Magazine/2014/Mar/cover-story-great-migration.
Published March 11, 2014. Accessed 7 Aug 2015.

3. Silverman K, Schaub H, Lowenstein D. Who’s going to care? Analysis and
recommendations for building New York’s care coordination and care
management workforce. New York, NY: Primary Care Development
Corporation; 2015. http://www.pcdc.org/resources/publications/
carecoordinationreportfinal2 . Accessed 24 Aug 2015.

4. Quan X, Joseph A, Keller A, Taylor E. Designing safety-net clinics for
innovative care delivery models. California Healthcare Foundation: Oakland,
CA; 2011. http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/
PDF%20D/PDF%20DesigningClinicsInnovativeCareDeliveryModels .
Accessed 3 Sept 2015.

5. Dougherty R, Crowley R. Principles supporting dynamic clinical care teams:
an American College of Physicians position paper. Ann Fam Med. 2013;
159(9):620–6.

6. Hein R. 7 healthcare IT roles that are transforming tech careers. CIO Web
site. http://www.cio.com/article/2385786/it-strategy/7-healthcare-it-roles-
that-are-transforming-tech-careers.html. Published May 16, 2013. Accessed
10 Aug 2015.

7. Altschuler J, Margolius D, Bodenheimer T, Grumbach K. Estimating a
reasonable patient panel size for primary care physicians with team-based
task delegation. Ann Fam Med. 2012;10:396–400.

8. Auerbach DI, Chen PG, Friedberg MW, Reid RO, Lau C, Mehrotra A. Nurse-
managed health centers and patient-centered medical homes could mitigate
expected primary care physician shortage. Health Aff. 2013;32(11):1933–41.

9. Walston S, Lazes P, Sullivan P. Improving hospital restructuring: lessons
learned. Health Care Manage Rev. 2004;29(4):309–19.

10. Curson JA, Dell ME, Wilson RA, Bosworkth DL, Balduf B. Who does workforce
planning well? Workforce review team rapid review summary. Int J Health
Care Qual Assur. 2010;23(1):110–9.

11. Weick KE. Management of organizational change among loosely coupled
elements. In: Weick K, editor. Making sense of the organization. Malden, MA:
Blackwell; 2001.

12. Schrock G. Connecting people and place prosperity: workforce
development and urban planning in scholarship and practice. J Plan Lit.
2014;29(3):257–71.

13. Dussault G, Dubois CA. Human resources for health policies: a critical
component in health policy. Hum Resour Health. 2003;1(1). doi:10.1186/
1478-4491-1-1.

14. Weick KE. Making sense of the organization: the impermanent organization
(V2). West Sussex: John Wiley & Sons; 2009.

15. Orton JD, Weick KE. Loosely coupled systems: a reconceptualization. Acad
Manage Rev. 1990;15(2):203–23.

16. Beekun RI, Glick WH. Organization structure from a loose coupling
perspective: a multidimensional approach. Decis Sci. 2001;32(2):227–50.

17. Burke WW. Changing loosely coupled systems. J Appl Behav Sci. 2014;50(4):
423–44.

18. Thompson JD. Organization in action. New York, NY: McGraw-Hill; 1967.
19. Weick KE. Educational organizations as loosely coupled systems. Adm Sci Q.

1976;21:1–16.

20. Heldal F. Multidisciplinary collaboration as a loosely coupled system:
integrating and blocking professional boundaries with objects. J Interprof
Care. 2010;24(1):19–30.

21. Thompson JD. Organizations in action: social science bases of administrative
theory. 7th ed. New Brunswick, New Jersey: Transaction Publishers; 2010.

22. Chase D. Montefiore Medical Center: integrated care delivery for vulnerable
populations. New York, NY: The Commonwealth Fund; 2010. http://www.
commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/
1448_Chase_Montefiore_Med_Ctr_case_study_v2 . Accessed 10 Aug 2015.

23. Permanente K. Jobs of the Future: workforce planning for 21st century care.
Oakland, CA: Kaiser Permanente; 2014. http://www.seiu-uhw.org/files/2015/
10/JobsoftheFuture-FinalReport-Nov2014 . Accessed 13 Aug 2015.

24. Kochan T, Eaton A, McKersie R, Adler P. Health together: the labor
management partnership at Kaiser Permanente. Ithaca, NY: Cornell
University Press; 2009.

25. Weick KE. Social psychology of organizing. 2nd ed. New, NY: McGraw-Hill; 1979.
26. Giloth RP. Workforce intermediaries for the 21st century. Philadelphia, PA:

The American Assembly, Columbia University; 2004.
27. Weick KE. Organizational redesign as improvisation. In: Huber G, Glick W,

editors. Organizational change and redesign. New York, NY: Oxford
University Press; 1993.

• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research

Submit your manuscript at
www.biomedcentral.com/submit

Submit your next manuscript to BioMed Central
and we will help you at every step:

Pittman and Scully-Russ Human Resources for Health (2016) 14:56 Page 15 of 15

http://www.hhnmag.com/Magazine/2014/Mar/cover-story-great-migration

http://www.pcdc.org/resources/publications/carecoordinationreportfinal2

http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20D/PDF%20DesigningClinicsInnovativeCareDeliveryModels

http://www.cio.com/article/2385786/it-strategy/7-healthcare-it-roles-that-are-transforming-tech-careers.html

http://dx.doi.org/10.1186/1478-4491-1-1

http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct/1448_Chase_Montefiore_Med_Ctr_case_study_v2

http://www.seiu-uhw.org/files/2015/10/JobsoftheFuture-FinalReport-Nov2014

Discussion
Core values and a centralized vision
Transparency and early dialogue
Innovations to workflow
New patterns of coupling
Maturing the WFPD model through intermediary functions
An emerging framework
Conclusions

show [a]

Acknowledgements
Funding
Availability of data and materials
Authors’ contributions
Authors’ information
Competing interests
Consent for publication
Ethics approval and consent to participate
Author details
References

By Thomas C. Ricketts and Erin P. Fraher

Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected

ABSTRACT 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.

H
ealth care professionals are be-
ing challenged to find new ways
to organize care and develop
systems that hold providers ac-
countable for the quality, cost,

and patient experience of care.1 The once in-
cremental pace of change is accelerating, and
there is evidence that long-standing paradigms
are dramatically shifting.2 For example, the rela-
tively slow acceptance of prepaid and managed
care systems is being replaced by the rapid adop-
tion of bundled and risk-based payment mod-
els.3,4 Early adopters of accountable care organi-
zations (ACOs) are finding that their workforce
is shifting from acute care to community- and
home-based settings with increasing roles for
physicians, nurses, social workers, patient navi-
gators and outreach coordinators, and other
clinicians in providing enhanced care coordina-
tion, better medication management, and im-
proved care transitions.5

The training of health professionals, however,
lags behind these reforms because it remains
largely insulated from change behind the walls
of schools of medicine, dentistry, pharmacy, and
nursing. Medical training is done primarily in
hospitals, while the greatest challenges are
found in coordinating care in multiple out-
patient settings. This article describes how
health workforce policy was done in the past.
It illustrates some of the specific changes under
way and how they are changing the health care
workforce. Further, it suggests that closer links
should be built between the day-to-day caring for
patients and the training of the people who de-
liver that care.

Workforce Policy Center Stage Again
Health workforce policy took center stage in an
earlier Health Affairs thematic issue in 2002.6

Articles in that issue described future efforts to

doi: 10.1377/hlthaff.2013.0531
HEALTH AFFAIRS 32,
NO. 11 (2013): 1874–1880
©2013 Project HOPE—
The People-to-People Health
Foundation, Inc.

Thomas C. Ricketts (tom_
ricketts@unc.edu) is the
deputy director of the Cecil G.
Sheps Center for Health
Services Research and a
professor in the Departments
of Health Policy and
Management and Social
Medicine at the University of
North Carolina at Chapel Hill.

Erin P. Fraher is an assistant
professor in the Departments
of Family Medicine and
Surgery, University of North
Carolina at Chapel Hill.

1874 Health Affairs November 2013 32:11

Overview

Downloaded from HealthAffairs.org on February 23, 2020.
Copyright Project HOPE—The People-to-People Health Foundation, Inc.

shape the clinical workforce as a “dream”7 or
subject to “hand-to-hand” combat.8 The “hands”
in thiscase weredescribedby KevinGrumbach as
the “heavy hand” of government regulation and
the “invisible hand” of market forces that con-
stantly pushed the United States into a rolling
series of surpluses followed by shortages.8 The
“dream,” as Uwe Reinhardt saw it, was that reg-
ulation and control could actually work. He of-
fered in its place a change in policy to expose
physicians to the actual costs of their training
while pushing them to the right places and spe-
cialties with judiciously targeted tax-financed
loan repayment.7

In much of the rest of the world, coordinated
workforce planning that develops national and
regional goals has long been accepted as a legiti-
mate policy exercise. This work is achieved by
pairing technical workforce experts and policy
makers with clinicians and patients to guide the
structure of the health workforce—in both num-
bers and skill mix—to meet the needs of delivery
systems and thepopulation.9 IntheUnited States
a mix of government policies and professional
guidelines combine with strong market forces to
shape the health care workforce; the latter al-
most invariably dominates but with a recogni-
tion among most stakeholders that regulation is
necessary.10

As a result, the United States has forgone any
substantial investment in workforce planning
except for the veterans’ health system.11 The
United States has left it up to states, professional
associations, employers, payers, and other
stakeholders to negotiate their interests via the
market and the political process. The result is a
complex and uncoordinated web of training in-
stitutions efforts, licensing board rules, place-
ment programs such as the National Health
Service Corps, and payment regimes. These are
not compared or evaluated to determine if they
are producing the right people for the right work
to meet patients’ needs.
With many observers asking if there will be

enough providers to meet the needs of rapidly
innovating systems, this laissez-faire system is
now in flux. The Centers for Medicare and
Medicaid Services has funded numerous pilots
to identify new models for workforce develop-
ment and payment to support health system in-
novation. These pilots, however, are relatively
isolated and have not been linked in any system-
atic way to broader systems or structures that
govern the way we train, regulate, or deploy
the health workforce.
The earlier Health Affairs thematic issue raised

many familiar, unanswered questions, including
a fundamental one: How many of what kinds of
professionals with what competencies are need-

ed to care for our population? This issue asks the
same questions but adds another: What has
changed over the past ten years?
The Affordable Care Act has created a new

vocabulary to describe networks of providers
tied together to offer enhanced care coordina-
tion. The ACO and the patient-centered medical
home have become seemingly ubiquitous mod-
els for holding systems accountable for the care
provided to patients across community, ambula-
tory, and acute care settings. These emerging
models of integrated care have been abetted by
increasing market concentration in health care
delivery systems.
ACOs, which take on risk by having a portion

of their reimbursements tied to the outcomes of
care for a predetermined Medicare population,
are seeking to reduce costs and improve care by
ramping up screening and preventive care and
the coordination of services. This restructuring
will have far-reaching implications for how clin-
ical work is organized and compensated, with
more work shifting to lower-paid and allied
health workers who provide care in less costly
community- and home-based settings.

Teams And Workforce
Almost all of the new arrangements include
plans or structures that call for more “team-
based care” and make use of “enhanced” roles
for various professions, despite a lack of consen-
sus on what those two terms really mean. Teams
have been described as groups of people whose
roles continuously shift in response to internal
and external forces, including patient expecta-
tions; policy and payment changes; organiza-
tional factors; geographic proximity of other
providers; and professional regulation, training,
and attitudes.12,13 Broadly conceptualized, roles
within teams fall into two categories: lower-cost
health professionals acting as substitutes for
higher-cost ones (for example, nurse practi-
tioners for physicians), or lower-cost health
professionals functioning as supplements who
extend and enhance the work of others (for
example, navigators to coordinate care or dis-
charge planners to help patients make the tran-
sition from acute to postacute care). Despite the
numerous calls for more team-based models of
care, relatively little attention has been given to
how to prepare physicians, nurses, therapists,
technicians, and others already in the workforce
to practice in accountable or reformed teams.
Health care professionals have been seen more

as parts of a puzzle that need to be carefully fit
together into a transformed system of care than
as fungible resources that can be crafted or re-
made to help build a truly reformed and more

November 2013 32:11 Health Affairs 1875
Downloaded from HealthAffairs.org on February 23, 2020.

effective health care delivery system. For exam-
ple, although the use of electronic health records
(EHRs) has burgeoned with the implementation
of the federal program to certify and reward the
meaningful use of health information technolo-
gy, there is limited understanding of how health
professionals can work with EHRs to change the
flow of work or how work should be reconfigured
and reallocated among team members. EHRs are
shaping the work of clinicians as much as they
are being adopted for and adapted to current
practices. To be optimally effective, EHRs re-
quire broad and rapid adoption, practitioners
must pay constant attention to data entry, and
care patterns have to be reengineered to accom-
modate EHRs’ use.14,15

Projecting Supply, Demand, Need,
And Requirements
That workforce projections are controversial
should come as no surprise; any projection will
inevitably be ambushed by unknown or un-
expected factors and events that affect future
workforce supply and demand. The surprising
thing is that projections, whether based on em-
pirical models or “expert” opinion, are criticized
for not correctly predicting the future when their
purpose is almost always to change policies and
practices. Projections, when accepted as roughly
correct, are often followed by policy shifts that,
in turn, change the future supply or pipeline of
workforce production.
Projections turn out to be wrong either be-

cause it is not known how many physicians there
are16 or because there is a lack of understanding
of the true relationship between physician
supply and health outcomes.17 They are, in one
sense, “projectiles” shot across the bows of
policy makers to stimulate action; they paint a
picture of what is likely to happen if some desir-
able policy is not implemented. If a policy is
changed, then the projection is likely to turn
out wrong because it helped cause changes in
the factors that drove the model.
For example, the Graduate Medical Education

National Advisory Committee’s 1980 projection
of a physician surplus was used to justify cut-
backs in federal support to medical education,
thus changing medical school growth trends.
That policy shift reduced production and even-
tually led to a perceived shortage.18 The more
recent Association of American Medical Colleges
forecasts of shortages of physicians have similar-
ly prompted the expansion of existing and the
opening of new medical schools and have put
strong pressure on the debate over how to sup-
port graduate medical education to provide the
additional training necessary to produce practic-

ing physicians.19

Recent work has focused on developing dy-
namic projection models that are amenable to
changes in the assumptions on which they are
based and that allow policy makers to simulate
the effects of potential policy scenarios20 on
workforce supply and demand. This type of work
is supported by the National Center for Health
Workforce Analysis in the Department of Health
and Human Services, but the center struggles
with a lack of both up-to-date inventories of ex-
isting health professionals and a common data
set to measure practitioner capacity or simply
identify the location of practice.21,22

The modeling field in the United States and
other countries23 is moving toward using projec-
tions not as a method for generating one “right”
answer but as a way to educate health profession-
als and their associations, policy makers, and
other workforce stakeholders about the com-
plexity of projecting future workforce needs
and the effects of the policy options they have
at hand. Engaging stakeholders—particularly
clinicians—in themodeling process cangenerate
numerous desirable results, including a better
understanding of how rapid health system
change affects workforce deployment and im-
proved communication between the professions
and policy makers. Having clinicians involved in
modeling can also serve as a check on the “face
validity” of model outputs and can generate clin-
ical input in areas where data inputs are weak.
Stakeholders engaged in modeling can also help
identify ways to redesign care processes to ad-
dress workforce shortfalls or surpluses.
Models and projection thus cannot provide a

single “right” answer in a system that is rapidly
changing. The important thing is to have a model
that can be used to simulate the effect of policy
change and educate stakeholders about the
effects of policy options. For example, a model
might show that increasing graduate medical
education slots will likely have a relatively small
effect on the overall match of supply to need
compared to increasing productivity and delay-
ing retirement.
Efforts to model the nursing workforce have

been complicated by nursing’s persistent sine-
wave pattern of shortages prompting policy ac-
tions that, in turn, stimulate rapid growth lead-
ing to surpluses.24 Analyses of nurse supply and
demand remain doggedly unconnected to physi-
cian workforce projections. There are no exam-
ples of national models that simultaneously
project the supply of both professions despite
their substantial overlap in providing care.
Combining the two in projections is now an im-
perative given nurses’ complementary and sup-
plementary roles in delivering or supporting

Overview

1876 Health Affairs November 2013 32:11
Downloaded from HealthAffairs.org on February 23, 2020.

many of the new services required by ACOs and
patient-centered medical homes, such as care
coordination, patient navigation, transition
care, and population health management.
An obvious link would be in the production

and deployment of nurse practitioners and their
impact on the “effective supply” of primary care
practitioners,25,26 but including “nonphysicians”
in physician supply-demand calculations has
proved difficult. For example, in the develop-
ment of an index to identify shortage areas for
federal support, an intense battle was fought in a
special “negotiated rulemaking” committee
mandated by the Affordable Care Act over how
to count nurse practitioners and physician assis-
tants in a formula for proposed new Health
Professional Shortage Areas and Medically
Underserved Populations.27 Advocates from the
nurse practitioner and physician assistant pro-
fessions felt strongly that they should be as-
signed a weight of at least 0.75 full-time-equiva-
lent of a primary care physician to account for
their contribution to community-based primary
care. Counting them would often increase the
local supply above a shortage threshold, making
the community or population lose its designa-
tion and thus its eligibility for federal support.

Productivity In The Health Care
Workforce
The promise of technology as the way to improve
the quality of care and lower costs, especially via
the EHR, has been promoted on the basis of its
potential to improve productivity in the system
by making care more efficient and effective.28

This is essentially an economic calculus: Can
more be done and done better and at lower cost?
That question remains to be answered.
What the United States has done is rapidly

increase the number of people and types of work-
ers who are delivering care. Employment in the
health care sector grew rapidly between 2000
and 2010—at a rate of greater than 3 percent
annually—and even faster growth has been
projected for the following decade, but there
are signs of a slowdown in that growth.29 This
is in contrast to overall employment, which
shrank by 0.2 percent per year in the first decade
of this century and is projected to grow by only
1.3 percent during 2010–20.
Employment growth in ambulatory health

services has been strong at 3.3 percent per year,
with an anticipated increase to 3.7 percent.
These labor inputs may be growing faster than
patient care needs, thus making the overall
workforce less productive and efficient. On the
other hand, that same expanding workforce may
be generating greater value by improving out-

comes through better coordination and greater
intensityof care.Whetherthesystem isbecoming
more or less efficient in terms of value for money
because of the addition of new specialties or new
professions has seldom been asked30 and even
less often answered.31

Professions Unto Themselves
The United States accepts in policy and practice
the idea of “sovereign” and self-regulating pro-
fessions that have substantial control over their
place in the health care system. This approach
has meant that workforce policy has been largely
shaped around the demands of the professions
and not around the needs of the patients. The
question of whether the professions should con-
trol entry into their respective realms through
self-regulation remains largely out of the main-
stream of debate but is raised from time to time
by libertarian thinkers.32 There are very intense
battles over scope-of-practice rules, with ad-
vanced-practice nurses making strong claims
on primary care, nurse anesthetists being chal-
lenged over their contributions by anesthesiolo-
gists, and the development of dental therapists’
work being challenged by dentists. These con-
flicts are becoming sharper despite a body of
evidence that shows that most of these work
and professional roles are effective in saving
money and maintaining or improving quality.33

New and different types of health profession-
als—community health workers, patient navi-
gators, health coaches, care coordinators, and
more—are attempting to create their own space
in the health care delivery system as their con-
tributions to the new payment and organiza-
tional models become more apparent. The
emergence of new professions runs counter to
theories of how health care workers should func-
tion in teams adapting and “upskilling” existing
professional or paraprofessional roles to meet
patients’ needs.34

The progressive division of labor and the crea-
tion of specialized labor categories that are able
to do one focused job more efficiently than a
range of work has been the pathway to greater
productivity in manufacturing and other sectors
but to a lesser extent in health services. In the
health care realm, increasing specialization is
reflected in the growing complexity of how a
hospital is staffed to care for patients—a process
that has given us hospitalists, intensivists, noc-
turnalists, and other types of practitioners who
are defined by their functional role as much as by
their disciplinary specialization.35 The prolifera-
tion of new professions and professional roles
does not necessarily lead to greater efficiency
because, as David Meltzer and Jeanette Chung

◀

3%
Employment growth
Employment in the health
care sector grew more
than 3 percent a year
during 2000–10, compared
to a 0.2 percent annual
shrinkage in overall
employment growth in the
same decade.

November 2013 32:11 Health Affairs 1877
Downloaded from HealthAffairs.org on February 23, 2020.

point out, there are real costs associated with
coordination.35 Those costs have not been calcu-
lated or even anticipated in most of the calls for
reorganization using teams.
The rise of additional specialists and profes-

sions within the health care “team” in new mod-
els of care have made Irving Zola and Stephen
Miller’s description of long-term care common-
place:“In thecourse of…long term disorders, the
doctor recedes further and further into the back-
ground, eventually assuming the role of occa-
sional medical consultant.With this, the physio-
therapist, visiting nurse, dietician, prosthetist
becomes essentially ‘the doctor’ not only in
terms of primary day-to-day management, but
in terms of the transference relationship as
well.”36

The career paths for physicians, nurses, and
even dentists are multiplying. They involve serial
training in fellowships to acquire new techni-
ques and skills; adapt to shifts in practice focus;
and, more often, prepare them for a return or
to introduce them to a type of practice that is
more flexible—essentially a return to a generalist
role.37 At the simplest level of care, the nature of
laborfordirect careworkerswho feed,move,and
clean patients has become dominated by part-
time jobs with fewer and fewer benefits.38 To
achieve true integration, teams must accommo-
date the multiple needs of the people working
around the patient, including highly trained
physicians who seek professional satisfaction
andhigh rewards aswell as unlicensed personnel
whose formal connection to the system is tenu-
ous but whose practical training and skills are
often crucial in generating quality care and pa-
tient satisfaction.
The pressure to coordinate, or perhaps simply

serve as a traffic cop controlling, the flow of
practitioners around the patient, has emerged
as a true challenge. Atul Gawande’s description
of hismother’s careduring her knee replacement
gives a sense of what a contemporary hospital-
based team is like: It is large, potentially irratio-
nal, and likely to grow.39 We know far less about
what makes for an effective team of ambulatory
caregivers when it comes to managing transi-
tions for patients with complex chronic illnesses
from community to acute care settings and back.
If the workforce needs of the future are to be
adequately assessed, it is necessary to first get
a better handle on who will make up the work-
force in each setting in the future.

Training And Education As Field Of
Reform
Training professionals for the future of team-
based care has been recognized as a real chal-

lenge. The Institute of Medicine is currently
supporting a committee, the Global Forum on
Innovation in Health Professional Education, to
explore how best to promote “transdisciplinary
professionalism.” The group recognizes the
challenges of integrating the diverse cultures
and skill sets of the various professions, the
problem of teaching “followership” and leader-
ship, and the practical problem of measuring
how well a team works.
The National Center for Interprofessional

Practice and Education has been funded by the
Health Resources and Services Administration
to do similar work. These efforts follow on a
series of precursor programs in interdisciplinary
training that never quite found traction in for-
mal policy or in health professions training.40

Thecentraltask for reformedhealth care delivery
may indeed be to create and sustain teams of
different professional pedigrees. The question
is whether teams can be constructed around a
template or whether it must happen in practice
with ad hoc teams forming around the patient
and their needs.

Innovations In Training And
Education
The ways in which health care professionals are
taught are changing rapidly. Additionally, there
is pressure to streamline pathways into profes-
sions.41 Online courses, clinical simulators, and
learning teams have made education more flexi-
ble. Still, little is known about what constitutes
efficient and effective clinical training.42 The true
costs of preparing health professions are being
revealed by the rapid growth in the number of
private, including for-profit, health professions
institutions that have sprung up to meet demand
from prospective students.43 These include oste-
opathic medical schools and physician assistant
programs and umbrella “Health Science”
schools that provide training for nurses, thera-
pists, and technicians. Public community col-
leges in some states fill this niche, but the market

Training professionals
for the future of
team-based care has
been recognized as a
real challenge.

Overview

1878 Health Affairs November 2013 32:11
Downloaded from HealthAffairs.org on February 23, 2020.

has also responded vigorously to train workers,
especially allied health workers, for reformed, if
not fully coordinated, systems.44

The “safety net” of public clinics, hospitals,
and private charity caregivers is one place where
innovation in role assignment and integration of
multiple professions has been welcomed,45 but
the benefits are difficult to calculate. Community
health centers (also known as federally qualified
health centers) have become testing grounds for
a new approach to graduate medical education
through the Teaching Health Centers Program.46

Through this program, the new centers are
funded as temporary demonstrations whose
long-term outlook depends on future appropria-
tions.47 They do offer a new approach to meeting
the growing need for locations to provide grad-
uate medical education given the recent rapid
rise in the number of US medical school gradu-
ates and the apparent “bottleneck” that has
slowed growth in residency training and thus
physicians’ progression into the workforce.
Revolutionary changes in the nature and form

of health care delivery are reverberating back-
ward into medical education as leaders of the
new practice organizations demand that the ed-
ucational mission be responsive to their needs
for practitioners who can work with teams in
more flexible and changing organizations. In
the face of this pressure, the traditional response
of health educators—that they should have au-
tonomy in defining the educational mission—is
no longer viable. Instead, more explicit, formal,
and systemic linkages between practice and ed-
ucational institutions that are coordinated with
maintenance of certification and licensing are
inevitable.48 There are proposals to base certifi-
cation and licensure on actual performance and
patient care outcomes instead of on simply meet-

ing additional education and training require-
ments. 49 This new pressure to make medical
education at all levels more accountable to public
and patient needs means that we must measure
how medical education affects medical care out-
comes, not just the outputs of the programs and
institutions.

Conclusion
We often hear how the United States has a non-
system of health care—a faircharacterization of a
very adaptable sector of the economy that com-
bines rigid professional norms, rapid shifts in
staffing and deployment of workers to capture
funding streams, and the constant creation of
new work roles and employment opportunities.
It is largely these characteristics of the workforce
that have both constrained the coordination of
health care and allowed the system to grow very
rapidly. To blunt rising costs, it seems necessary
to find ways to temper this professional and oc-
cupational exuberance to achieve both greater
efficiency and effectiveness.
To anticipate these changes and prepare the

workforce for new roles, it will be necessary to
invest in workforce planning but not solely at the
macro level of overall supply. Investments are
needed in research and implementation studies
to help foster greater understanding about the
actual content of care that is required in the new
systems. Investments in research are also needed
to identify how best to allocate new caring roles
among a set of professions and disciplines that
are trained and deployed in a coordinated fash-
ion. Workforce planning needs to be more “bot-
tom up” as it seeks to identify the “right kind”
and the “right number” of workers. ▪

This work was supported in part by
contracts with the American College of
Surgeons and the Physicians Foundation.
The authors thank Laura Trude and Kelly

Quigley of the Health Workforce
Information Center at the University of
North Dakota for their assistance.

NOTES

1 Berwick DM, Hackbarth AD.
Eliminating waste in US health care.
JAMA. 2012;307(14):1513–6.

2 Berwick D. Escape fire: designs for
the future of health care. San
Francisco (CA): Jossey-Bass; 2004.

3 Marmor T, Oberlander J. From
HMOs to ACOs: the quest for the
Holy Grail in US health policy. J Gen
Intern Med. 2012;27(9):1215–8.

4 Emanuel EJ. Why accountable care
organizations are not 1990s man-
aged care redux. JAMA. 2012;
307(21):2263–4.

5 Silow-Carroll S, Edwards JN (Health

Management Associates, Lansing,
MI). Early adopters of the account-
able care model: a field report on
improvements in health care deliv-
ery [Internet]. New York (NY):
Commonwealth Fund; 2013 Mar
[cited 2013 Sep 24]. Available from:
http://www.commonwealthfund
.org/~/media/Files/Publications/
Fund%20Report/2013/Mar/1673_
SilowCarroll_early_adopters_ACO_
model

6 Iglehart JK. The woeful neglect of
health care workforce issues. Health
Aff (Millwood). 2002;21(5):7–8.

7 Reinhardt UE. Dreaming the
American dream: once more around
on physician workforce policy.
Health Aff (Millwood). 2002;21(5):
28–32.

8 Grumbach K. Fighting hand to hand
over physician workforce policy.
Health Aff (Millwood). 2002;21(5):
13–27.

9 Tomblin Murphy G, Mackenzie A,
Alder R, Langley J, Hickey M, Cook
A. Pilot-testing an applied compe-
tency-based approach to health hu-
man resources planning. Health
Policy Plan. 2012 Dec 18 [Epub

November 2013 32:11 Health Affairs 1879
Downloaded from HealthAffairs.org on February 23, 2020.

ahead of print].
10 Rice T. Can markets give us the

health system we want? J Health
Polit Policy Law. 1997;22(2):
383–426.

11 Lipscomb J, Kilpatrick KE, Lee KL,
Pieper KS. Determining VA physi-
cian requirements through empiri-
cally based models. Health Serv Res.
1995;29(6):697–717.

12 Laurant M, Harmsen M,
Wollersheim H, Grol R, Faber M,
Sibbald B. The impact of nonphysi-
cian clinicians: do they improve the
quality and cost-effectiveness of
health care services? Med Care Res
Rev. 2009;66(6 Suppl):36S–89S.

13 Porter ME, Pabo EA, Lee TH.
Redesigning primary care: a strate-
gic vision to improve value by orga-
nizing around patients’ needs.
Health Aff (Millwood). 2013;32(3):
516–25.

14 Holroyd-Leduc JM, Lorenzetti D,
Straus SE, Sykes L, Quan H. The
impact of the electronic medical re-
cord on structure, process, and out-
comes within primary care: a sys-
tematic review of the evidence. J Am
Med Inform Assoc. 2011;18(6):
732–7.

15 Kellermann AL, Jones SS.What it will
take to achieve the as-yet-unfulfilled
promises of health information
technology. Health Aff (Millwood).
2013;32(1):63–8.

16 Staiger DO, Auerbach DI, Buerhaus
PI. Comparison of physician work-
force estimates and supply projec-
tions. JAMA. 2009;302(15):
1674–80.

17 Goodman DC, Fisher ES. Physician
workforce crisis? Wrong diagnosis,
wrong prescription. N Engl J Med.
2008;358(16):1658–61.

18 Steinwachs D. GMENAC’s projection
of a future physician surplus.
Implications for HMOs. Group
Health J. 1983;4(1):7–11.

19 Kirch DG, Henderson MK, Dill MJ.
Physician workforce projections in
an era of health care reform. Annu
Rev Med. 2012;63:435–45.

20 Fraher EP, Knapton A, Sheldon GF,
Meyer A, Ricketts TC. Projecting
surgeon supply using a dynamic
model. Ann Surg. 2013;257(5):
867–72.

21 Lewin Group. The status of data
sources to inform health workforce
policy and supply adequacy.
Washington (DC): Office of the
Assistant Secretary for Planning and
Evaluation; 2010 May 6.

22 Bureau of Health Professions. The
physician workforce: projections
and research into current issues af-
fecting supply and demand.
Rockville (MD): Health Resources
and Services Administration;
2008 Dec.

23 Ono T, Lafortune G, Schoenstein M.

Health workforce planning in OECD
countries: a review of 26 projection
models from 18 countries. Paris:
Organization for Economic
Cooperation and Development;
2013.

24 Auerbach DI, Staiger DO, Muench U,
Buerhaus PI. The nursing workforce
in an era of health care reform. N
Engl J Med. 2013;368(16):1470–2.

25 Green LV, Savin S, Lu Y. Primary care
physician shortages could be elimi-
nated through use of teams, non-
physicians, and electronic commu-
nication. Health Aff (Millwood).
2013;32(1):11–9.

26 Newhouse RP, Weiner JP, Stanik-
Hutt J, White KM, Johantgen M,
Steinwachs D, et al. Policy implica-
tions for optimizing advanced prac-
tice registered nurse use nationally.
Policy Polit Nurs Pract. 2012;13(2):
81–9.

27 Department of Health and Human
Services. Negotiated Rulemaking
Committee on the Designation of
Medically Underserved Population
and Health Professional Shortage
Areas: final report to the secretary.
Washington (DC): HHS; 2011 Oct 31.

28 Fisher ES, Staiger DO, Bynum JP,
Gottlieb DJ. Creating accountable
care organizations: the extended
hospital medical staff. Health Aff
(Millwood). 2007;26(1):w44–57.
DOI: 10.1377/hlthaff.26.1.w44.

29 Altarum Institute, Center for
Sustainable Health Spending.
Health Sector Indicators: insights
from the Bureau of Labor Statistics
(BLS) August 2013 employment data
[Internet]. Washington (DC): The
Institute; 2013 Sep 9 [cited 2013
Oct 1]. (Labor Brief). Available from:
http://altarum.org/sites/default/
files/uploaded-related-files/CSHS-
Labor-Brief_September%202013

30 Kocher R, Sahni NR. Rethinking
health care labor. N Engl J Med.
2011;365(15):1370–2.

31 Ozcan YA, Luke RD. Health care
delivery restructuring and produc-
tivity change: assessing the Veterans
Integrated Service Networks (VISNs)
using the Malmquist approach. Med
Care Res Rev. 2011;68(1 Suppl):
20S–35S.

32 Svorny S. Medical licensing: an ob-
stacle to affordable, quality care.
Washington (DC): Cato Institute;
2008 Sep 17. (Policy Analysis
No. 621).

33 Dower C, Christian S, O’Neil E.
Promising scope of practice models
for the health professions. San
Francisco (CA): Center for the
Health Professions, University of
California, San Francisco; 2007.

34 Weinberg DB, Cooney-Miller D,
Perloff JN, Babinbgton L, Avgar AC.
Building collaborative capacity: pro-

moting interdisciplinary teamwork
in the absence of formal teams. Med
Care. 2011;49(8):716–23.

35 Meltzer DO, Chung JW. U.S. trends
in hospitalization and generalist
physician workforce and the emer-
gence of hospitalists. J Gen Intern
Med. 2010;25(5):453–9.

36 Zola IK, Miller SJ. The erosion of
medicine from within. In: Freidson
E, editor. The professions and their
prospects. Beverly Hills (CA): Sage;
1973. p. 165.

37 Kenagy GP, Schneidman BS,
Barzansky B, Dalton C, Sirio CA,
Skochelak SE. Guiding principles for
physician reentry programs. J
Contin Educ Health Prof. 2011;31(2):
117–21.

38 Konrad TR. The direct care worker:
overcoming definitions by negation.
Res Sociol Health Care. 2011;29:
43–75.

39 Gawande A. Big med. New Yorker.
2012 Aug 13.

40 Baldwin DC Jr. Some historical notes
on interdisciplinary and interpro-
fessional education and practice in
health care in the USA. 1996. J
Interprof Care. 2007;21(Suppl 1):
23–37.

41 Emanuel EJ, Fuchs VR. Shortening
medical training by 30%. JAMA.
2012;307(11):1143–4.

42 Greiner AC, Knebel E, editors.
Health professions education: a
bridge to quality. Washington (DC):
National Academies Press; 2003.

43 Mychaskiw G 2nd, Wiltshire W. A
for-profit medical school. Acad Med.
2009;84(1):5.

44 Lewin ME, Altman S, editors.
America’s health care safety net: in-
tact but endangered. Washington
(DC): National Academies Press;
2000.

45 Chen C, Chen F, Mullan F. Teaching
Health Centers: a new paradigm in
graduate medical education. Acad
Med. 2012;87(12):1752–6.

46 Rich EC. Commentary: Teaching
Health Centers and the path to
graduate medical education reform.
Acad Med. 2012;87(12):1651–3.

47 Stone RI, Bryant N. The impact of
health care reform on the workforce
caring for older adults. J Aging Soc
Policy. 2012;24(2):188–205.

48 Frankford DM, Konrad TR.
Responsive medical professional-
ism: integrating education, practice,
and community in a market-driven
era. Acad Med. 1998;73(2):138–45.

49 Chen C, Petterson S, Phillips RL,
Mullan F, Bazemore A, O’Donnell
SD. Toward graduate medical edu-
cation (GME) accountability: mea-
suring the outcomes of GME insti-
tutions. Acad Med. 2013;88(9):
1267–80.

Overview

1880 Health Affairs November 2013 32:11
Downloaded from HealthAffairs.org on February 23, 2020.

What Will You Get?

We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.

Premium Quality

Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.

Experienced Writers

Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.

On-Time Delivery

Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.

24/7 Customer Support

Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.

Complete Confidentiality

Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.

Authentic Sources

We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.

Moneyback Guarantee

Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.

Order Tracking

You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.

Order Now Talk to Us

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.

Preferred Writer

Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.

Grammar Check Report

Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.

One Page Summary

You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.

Plagiarism Report

You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.

Free Features $66FREE

Most Qualified Writer $10FREE
Plagiarism Scan Report $10FREE
Unlimited Revisions $08FREE
Paper Formatting $05FREE
Cover Page $05FREE
Referencing & Bibliography $10FREE
Dedicated User Area $08FREE
24/7 Order Tracking $05FREE
Periodic Email Alerts $05FREE

Our Services

Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.

On-time Delivery
24/7 Order Tracking
Access to Authentic Sources

Academic Writing

We create perfect papers according to the guidelines.

Professional Editing

We seamlessly edit out errors from your papers.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Thorough Proofreading

We thoroughly read your final draft to identify errors.

Delegate Your Challenging Writing Tasks to Experienced Professionals

Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!

Check Out Our Sample Work

Dedication. Quality. Commitment. Punctuality

It May Not Be Much, but It’s Honest Work!

Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.

Call Us +1 (877) 657-8180 Discuss Order Details Now

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.

Clear elicitation of your requirements.
Customized writing as per your needs.

We Mirror Your Guidelines to Deliver Quality Services

We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.

Proactive analysis of your writing.
Active communication to understand requirements.

We Handle Your Writing Tasks to Ensure Excellent Grades

We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.

Thorough research and analysis for every order.
Deliverance of reliable writing service to improve your grades.

Place an Order Start Chat Now

53/1 Dis

What Will You Get?

Premium Quality

Experienced Writers

On-Time Delivery

24/7 Customer Support

Complete Confidentiality

Authentic Sources

Moneyback Guarantee

Order Tracking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Areas of Expertise

Essay

Thesis

Presentation

Dissertation

Term Paper

Research Paper

Book Review

Assignment

Report

Case Study

Letter

Article

Coursework

Speech

Q & A

Critical Thinking

Trusted Partner of 9650+ Students for Writing

Preferred Writer

Grammar Check Report

One Page Summary

Plagiarism Report

Free Features $66FREE

Our Services

Academic Writing

Professional Editing

Thorough Proofreading

Thorough Proofreading

Delegate Your Challenging Writing Tasks to Experienced Professionals

Check Out Our Sample Work

It May Not Be Much, but It’s Honest Work!

0+

Happy Clients

0+

Words Written This Week

0+

Ongoing Orders

0%

Customer Satisfaction Rate

Process as Fine as Brewed Coffee

Share Your Requirements

Place Order & Deposit Funds

Release Payment to Your Writer

See How We Helped 9000+ Students Achieve Success

We Analyze Your Problem and Offer Customized Writing

We Mirror Your Guidelines to Deliver Quality Services

We Handle Your Writing Tasks to Ensure Excellent Grades