Strategies for Government

Studies have shown that working in high-functioning teams improves worker and learner well-being. State and federal policymakers can support and encourage team-based care through strategies that include:

• Establishing payment models, funding, and technical support for interprofessional, team-based care, particularly in high need communities
• Aligning state scope of practice laws or creating a federal law

‍Evidence

The Center for Medicare and Medicaid Innovation has launched more than 40 new payment models in an attempt to improve care.¹ Some values-based payment models,² including hybrid reimbursement models (traditional fee-for-service plus lump-sum or per-person payments), have been shown to encourage integrated primary care because incentives are shared across a team of clinicians as they provide more comprehensive patient services that are not typically covered under fee-for-service reimbursement.³ These hybrid payment models include the patient-centered medical home model and the Comprehensive Primary Care model, which transitioned to the Comprehensive Primary Care Plus model in 2017.⁴ However, analysis has shown that these payment models struggle with inadequate lump-sum or per-person payments to enable primary care practices to fully invest in staff and other resources that enable integrated, team-based care.^3,5 To support these payment models, revenue must be predictable and sustainable and must come from multiple payer sources.³ Accountable care organizations (ACOs), another value-based payment model, also promote team-based care, as hospitals, physicians, and other clinicians voluntarily work together to coordinate care for Medicare patients.^3,4 When ACOs provide high-quality care and save Medicare dollars, members share in the savings. 

High-functioning teams utilize each team member’s full set of knowledge and skills. Scope of practice laws, which are currently in the purview of state governments, dictate the type of care health workers can legally provide, and they vary widely from state to state.^6-8 A systematic review of nurse practitioner (NP) scope of practice laws found that states that allow NPs greater scope of practice authority have a higher number of NPs, more care delivered by NPs, and greater utilization of healthcare services, particularly in underserviced areas.⁹ Likewise, a longitudinal analysis of county-level data across the U.S. showed that states with full NP scope of practice regulation had significantly more NPs in rural and primary care health professional shortage area (HPSA) counties than states with reduced or restricted scope of practice.¹⁰ NPs working in states with full scope of practice laws have better role visibility and support as well as improved relations with administrators.¹¹ 

‍Resources

The National Academies of Sciences, Engineering, and Medicine Consensus Study Report on Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care discusses interprofessional team-based care in the setting of primary care and makes recommendations including:

• Payers should evaluate and disseminate payment models based on the ability of those models to promote the delivery of high-quality primary care
• Payers using a fee-for-service (FFS) payment model for primary care should shift toward hybrid (part FFS, part capitated) models. Hybrid models should: pay prospectively for interprofessional, integrated, team-based care, be risk adjusted for medical and social complexity, allow for investment in team development, practice transformation, and the infrastructure to design, use, and maintain necessary digital health technology, align with incentives for measuring and improving outcomes for attributed populations

The National Advisory Council on Nurse Education and Practice report on Incorporating Interprofessional Education and Practice into Nursing and the Advisory Committee on Interdisciplinary Community-Based Linkages report on Preparing the Current and Future Health Care Workforce for Interprofessional Practice in Sustainable, Age-Friendly Health Systems make recommendations for federal funding to improve interprofessional education.

The Health Workforce Technical Assistance Center at the University of Albany provides an overview of key issues and challenges related to scope of practice laws, relevant information and research, model practice acts, and innovations in health professions regulation.

The National Conference of State Legislators Scope of Practice Policy website provides an inventory of state polices for behavioral health providers, nurse practitioners, oral health providers, pharmacists, and physician assistants. 

‍Spotlights

‍The Health Resources and Services Administration (HRSA) partnered with multiple foundations to establish the National Center for Interprofessional Practice and Education, which provides leadership, evidence, and resources that inform interprofessional education and collaborative practice. HRSA also funds grants for interprofessional collaboration, such as the Nurse Education, Practice, Quality and Retention (NEPQR) Interprofessional Collaborative Practice Program (IPCP). 

The Agency for Healthcare Research and Quality (AHRQ) created the TeamSTEPPS program, which is an evidence-based set of teamwork tools meant to improve team dynamics and patient outcomes. 

‍Franson and Gilliam (2019) describe a change in Colorado law that allows pharmacy schools to expand their students’ clinical experiences and learn from other practitioners, such as dentists, nurses, physicians, social workers, and others.

The U.S. Department of Veterans Affairs (VA) is currently developing national standards of practice that will outline the scope of practice for approximately 50 health care occupations, enabling all VA facilities to be aligned in the care that workers provide, regardless of state regulations.

‍References

1. “What is CMMI?” and 11 other FAQs about the CMS Innovation Center. Kaiser Family Foundation. Published February 27, 2018. 
2. Value-based payment as a tool to address excess US Health spending. Health Affairs. Published December 1, 2022. 
3. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. The National Academies Press; 2021. 
4. Berenson RA, Shartzer A, Murray RC. Strengthening Primary Care Delivery through Payment Reform: Options and Experience. Urban Institute. Published July 2020.  
5. Peikes D, Anglin G, Dale S, et al. Evaluation of the Comprehensive Primary Care Initiative: Fourth annual report. Mathematica Policy Research; 2018. 
6. American Dental Hygienists Association. Restorative services: Scope of practice. 
7. American Association of Nurse Practitioners. 2023 nurse practitioner state practice environment. Published March 2023. 
8. National Alliance of State Pharmacy Associations. Resources: Pharmacist prescribing: Tobacco cessation aids. Published February 10, 2021. 
9. 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. 
10. Xue Y, Kannan V, Greener E, et al. Full scope-of-practice regulation is associated with higher supply of nurse practitioners in rural and primary care health professional shortage counties. J Nurs Reg. 2018;8(4):5-13.
11. Poghosyan L, Stein JH, Liu J, Spetz J, Osakwe ZT, Martsolf G. State-level scope of practice regulations for nurse practitioners impact work environments: Six state investigation. Res Nurs Health. 2022;45(5):516-524. 

‍

State and federal policymakers can strengthen or establish evidence, standards, and programs to support safe staffing. Approaches include:

• Investing in workforce programs to ensure a sufficient and well-trained workforce, especially in underserved areas
• Enhancing payment for critical workforce (e.g., increasing Medicaid payment rates, wage pass-through programs)
• Establishing minimum staffing standards (e.g., mandated staff-to-patient ratios or staffing committees, public reporting of staffing information)
• Regulating mandatory overtime and consecutive work hours

Evidence

The Health Resources and Services Administration’s (HRSA’s) Title VII and Title VIII are workforce development programs that are authorized under the Public Health Service Act. Multiple studies have shown that these programs, which are meant to bolster the dental, medical, and nursing workforce and improve access to care for disadvantaged groups,¹ have strengthened and diversified the workforce, especially in primary care.^2-5 The federal government also funds Teaching Health Center Graduate Medical Education programs (THCs) to support community-based residencies for dentists and physicians.⁶ Since 2010, 2,027 new physicians and dentists have joined the workforce, many serving in or near their underserved residency sites.⁷

The National Health Service Corps (NHSC) provides loan repayment and scholarships to bolster the healthcare workforce in underserved areas. Studies have shown that participants in the NHSC are more likely to work in rural and health professional shortage areas (HPSAs).^8-9 The Conrad 30 waiver program, which waives the two-year foreign residency requirement for J-1 international medical graduates who practice in HPSAs, have mixed results in terms of bolstering staffing in underserved areas, especially for the long-term.^10-14

Studies generally show Medicaid payments are lower than Medicare.^15,16 In 2019, the Medicaid-to-Medicare Fee Index was 0.72 for all services across the U.S. under fee-for-service Medicaid.¹⁷ Studies have also shown nursing home staffing levels are associated with Medicaid reimbursement rates¹⁸ and rate increases in states were associated with improved staffing in nursing homes.^19,20 Additional payment strategies, such as cost-based payments and wage pass-through programs (Medicaid funds provided expressly for the purpose of increased compensation for direct care workers) have also demonstrated effect on increasing wages and staffing in nursing homes,^18,21,22 although the research is somewhat dated.

State minimum nurse staffing ratios have been associated with increased nurse staffing and retention^23,24 and lower patient mortality.²⁵ Although one study of California’s mandated nurse staffing ratios showed mixed results in quality outcomes and staffing improvements largely predicated on pre-mandate staffing levels,²³ another study found mandated ratios were associated with some hospitals cutting other positions, such as nurse aids.²⁶ A study of Massachusetts’ intensive care unit staffing mandate did not find increased nurse staffing or changes in patient outcomes compared to other states.²⁷ Evidence for mandatory hospital nurse staffing committees is positive but limited, showing increased nurse staffing and nurses’ perception of having voice in patient care.²⁸ Mandated public reporting of staffing levels has shown both positive and neutral effects on nurse staffing,^29,30 however, one study suggests staffing committees and public reporting alone were not as effective in increasing RN staffing as the California minimum staffing law.³¹

Work hour regulations – allowing nurses to refuse mandatory overtime requests and restricting working consecutive hours – are associated with reducing long nurse work hours,³² which has further been associated with nurse turnover.³³ Physician resident work hour restrictions have generally shown favorable or no effect on resident wellness and patient outcomes, however, concerns have been raised around resident education (e.g., educational attendance, caseloads).³⁴ Although one study examining first-year complication rates of pediatric surgeons who trained under duty hour restrictions showed no significant difference compared to previously published rates.³⁵

‍Resources

Invest in Workforce Programs

The Health Resources and Services Administration developed a Health Workforce Strategic Plan 2021. Goals and recommendations center around expanding the health workforce, improving its distribution, offering additional education and training to improve the quality of care, and using data and evidence to inform initiatives.

The American Association of Colleges of Nursing outlines strategies state and federal governments are taking to address the nurse faculty shortage, including:

• Supplementing faculty salaries
• Offering tax incentives
• Funding existing and new workforce development programs

The Senate Health, Education, Labor, & Pension (HELP) Committee hearing on February 16, 2023 focused on addressing workforce shortages, including increasing investments in graduate medical education (GME), nursing education, and National Health Service Corps and Nurse Corps, which offer scholarships and loan repayments to clinicians practicing in underserved areas.

‍Enhance Payment for Critical Workforce

The Medicaid and CHIP Payment Access Commission (MACPAC) issue brief on State Policy Levers to Address Nursing Facility Staffing Issues discusses 3 strategies to improve nursing home staffing:

• Increasing Medicaid payment rates
• Incentivizing facilities to spend more on staff (e.g., pass-through payment policies)
• Minimum staffing standards.

‍KFF’s Annual Medicaid Budget Survey tracks changes in reimbursement rates. In FY 2022, all but one state reported increasing Medicaid reimbursement rates for at least one provider category and several states reported comprehensive rate reform analyses.

‍Establish Minimum Staffing Standards

The Department of Health and Human Services released a proposal for minimum staffing standards to enhance safety and quality in nursing homes. Nursing homes that receive reimbursement from Medicare and Medicaid would be required to provide residents with 0.55 of registered nurse care and 2.45 hours of nurse aide care per resident per day. These standards, if adopted, would exceed existing minimum staffing standards in nearly every state, resulting in increased staffing in approximately 75% of nursing homes. 

The Office of the Inspector General report CMS Use of Data on Nursing Home Staffing: Progress and Opportunities to Do More recommends:

• Reporting staffing turnover and tenure
• Increasing non-nurse staff information
• coordinating with state survey agencies to strengthen oversight.

‍de Cordova et al. (2019) provide an overview of state public reporting on nurse staffing legislation and compare the reporting requirements in 8 states (Table 1). 

The American Nurses Association provides information on safe nurse staffing, including which states have mandated nurse staffing committees, nurse to patient ratios, and reporting requirements.

‍Mandatory Overtime Regulations

Deering (2022) summarizes mandatory overtime laws applicable to nurses by state.

‍Spotlights

‍The National Governors Association reports on state strategies to recruit and retain health workers, including data collection, career pathways, bolstering the nursing and direct care workforces, funding healthcare workforce initiatives. Additional state spotlights include:
‍
South Carolina passed legislation to supplement nurse faculty salaries and reduce costs for students enrolled in graduate-level programs that prepare them to become nurse educators.
‍
Oregon created the Home Care Commission for direct care workers to provide training and certification and create a public registry for the public to find workers. The Commission also uses collective bargaining to set competitive wages for direct care workers and offers pathways to higher-paying careers.

The Centers for Medicare & Medicaid Services (CMS) requires staffing in nursing homes to be reported on its Care Compare website. In addition, in July 2022 additional requirements were released including annual turnover rates for nurses and administrators as well as nurse staffing hours per resident day on weekends; and in early 2022 CMS launched a mixed-methods Study to Inform Minimum Staffing Requirements for Nursing Homes. Results are expected in 2023.

‍References

1. Ziemann M, Orban J, Vichare A, Batra S. How is the health workforce educated and trained? An examination of social mission in health professions education. Fitzhugh Mullan Institute for Health Workforce Equity, George Washington University. May 2022. 
2. Rittenhouse DR, Fryer GE, Phillips RL, et al. Impact of Title VII training programs on community health center staffing and National Health Service Corps participation. Ann Fam Med. 2008;6(5):397-405. 
3. Chou CF, Holtzman JS, Rogers S, Chen C. The impact of Title VII dental workforce programs on dentists' practice location: a difference-in-differences analysis. Acad Med. 2020;95(3):442-449. 
4. Philips RL, Dodoo MS, Petterson S, et al. Specialty and geographic distribution of the physician workforce: What influences medical student & resident choices? Robert Graham Center. March 2, 2009. 
5. Krist AH, Johnson RE, Callahan D, Woolf SH, Marsland D. Title VII funding and physician practice in rural or low-income areas. J Rural Health. 2005;21(1):3-11.
6. Teaching Health Center Graduate Medical Education (THCGME) program. Health Resources & Services Administration. Updated July 2023. 
7. Levin Z, Meyers P, Peterson L, Habib A, Bazemore A. Practice intentions of family physicians trained in teaching health centers: the value of community-based training. J Am Board Fam Med. 2019;32(2):134-135. 
8. Brooks RG, Mardon R, Clawson A. The rural physician workforce in Florida: A survey of U.S.- and foreign-born primary care physicians. J Rural Health. 2003;19(4):484-491. 
9. Negrusa S, Hogan P, Ghosh P, Watkins L. National Health Service Corps – An Extended Analysis. The Lewin Group; 2016. 
10. Kahn TR, Hagopian A, Johnson K. Retention of J-1 visa waiver program physicians in Washington state’s health professional shortage areas. Acad Med. 2010;85(4):614-621. 
11. Ogunyemi D, Edelstein R. Career intentions of U.S. medical graduates and international medical graduates. J Natl Med Assoc. 2007;99(10):1132. 
12. Thompson MJ, Hagopian A, Fordyce M, Hart LG. Do international medical graduates (IMGs) “fill the gap” in rural primary care in the United States? A national study. J Rural Health. 2009;25(2):124-134.
13. Mertz E, Jain R, Breckler J, Chen E, Grumbach K. Foreign versus domestic education of physicians for the United States: A case study of physicians of South Asian ethnicity in California. J Health Care Poor Underserved. 2007;18(4):984-993. 
14. Crouse BJ, Munson RL. The effect of the physician J-1 visa waiver on rural Wisconsin. WMJ. 2006;105(7):16-20.  
15. Medicaid and CHIP Payment and Access Commission. Medicaid hospital payment: A comparison across states and to Medicare. Published April 2017. 
16. Zhu JM, Renfro S, Watson K, Deshmukh A, McConnell KJ. Medicaid reimbursement for psychiatric services: Comparisons across states and with Medicare. Health Affairs. 2023;42(4):556-565. 
17. KFF. State health facts: Medicaid-to-Medicare fee index. 
18. Harrington C, Swan JH, Carrillo H. Nurse staffing levels and Medicaid reimbursement rates in nursing homes. Health Serv Res. 2007;42(3):1105-1129.
19. Bowblis JR, Applebaum R. How does Medicaid reimbursement impact nursing home quality? The effects of small anticipatory changes. Health Serv Res. 2017;52(5):1729-1748.
20. Hackmann MB. Incentivizing better quality of care: The role of Medicaid and competition in the nursing home industry. Am Econ Rev. 2019;109(5):1684-1716. 
21. Feng Z, Lee YS, Kuo S, et al. Do Medicaid wage pass-through payments increase nursing home staffing? Health Serv Res. 2010;45(3):728-747. 
22. Office of the Assistant Secretary for Planning and Evaluation (ASPE). State wage pass-through legislation: An analysis. December 20, 2002. 
23. Mark BA, Harless DW, Spetz J, Reiter KL, Pink GH. California’s minimum nurse staffing legislation: Results from a natural experiment. Health Serv Res. 2013;48(2pt1):435-454. 
24. McHugh MD, Aiken LH, Sloane DM, Windsor C, Douglas C, Yates P. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: A prospective study in a panel of hospitals. Lancet. 2021;397(10288):1905-1913. 
25. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res. 2010;45(4):904-921. 
26. Spetz J, Chu L, Blash L. The Impact of the COVID-19 Pandemic on California’s Registered Nurse Workforce: Preliminary Data. University of California San Francisco, Health Workforce Research Center on Long-Term Care; 2021.
27. Law AC, Stevens JP, Hohmann S, Walkey AJ. Patient outcomes after the introduction of statewide intensive care unit nurse staffing regulations. Crit Care Med. 2018;46(10):1563-1569. 
28. Jones T, Heui Bae S, Murry N, Hamilton P. Texas nurse staffing trends before and after mandated nurse staffing committees. Policy Polit Nurs Pract. 2015;16(3‐4):79‐96. 
29. De Cordova PB, Rogowski J, Riman KA, McHugh MD. Effects of public reporting legislation of nurse staffing: A trend analysis. Policy Polit Nurs Pract. 2019;20(2):92‐104. 
30. De Cordova PB, Johansen ML, Zha P, Prado J, Field V, Cadmus E. Does public reporting of staffing ratios and nursing home compare ratings matter? J Am Med Dir Assoc. 2021;22(11):2373-2377. 
31. Han X, Pittman P, Barnow B. Alternative approaches to ensuring adequate nurse staffing. Med Care. 2021;59(10 Suppl 5):S463-S470. 
32. Bae SH, Yoon J. Impact of states’ nurse work hour regulations on overtime practices and work hours among registered nurses. Health Serv Res. 2014;49(5):1638-1658.
33. Bae SH. Association of work schedules with nurse turnover: A cross-sectional national study. Int J Public Health. 2023;68:1605732.
34. Bolster L, Rourke L. The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: An updated systematic review. J Grad Med Educ. 2015;7(3):349-363. 
35. Fleming MA, Etchill EW, Marsh KM, et al. A dual-institutional study on first-year practice outcomes of pediatric surgeons who trained in the era of work hour restrictions. Pediatr Surg Int. 2022;38(2):277-283.

Laws, regulations, policies, and standards established by governmental and private entities contribute to the administrative and documentation burden identified as a driver of health worker burnout. State and federal policymakers can address these administrative requirements. Strategies include:

• Reviewing and revising administrative (e.g., prior authorizations) policies and requirements to standardize and reduce burden
• Reviewing and streamlining licensing and credentialing requirements
• Advancing new standards for health IT (e.g., EHR interoperability, user experience)

‍Evidence

The Council for Affordable Quality Healthcare (CAQH) estimates that nine administrative tasks cost the U.S. healthcare system $60 billion dollars in 2022 and nearly $25 billion could be saved by transitioning to fully electronic submissions for these tasks with providers saving 4 to 15 minutes per transaction.¹ In 2018, the Office of the Inspector General’s audit of Medicare Advantage organizations found that prior authorizations totaled 24 million in 2016 with 1 million denied on the first try.² In 2015, the OIG found that 56% of audited prior authorizations and payment claims were inappropriately denied.² 

An analysis of executive orders during the COVID-19 pandemic that lifted restrictions on licensing and credentialing for advanced practice registered nurses (APRNs) expanded APRNs’ time with patients and enabled them to take on more new patients. Benefits were particularly positive for APRNs working in private offices and with underserved patients.³ Researchers have estimated that standardizing the information insurers require could save $35 billion per year; additionally, creating a centralized claims clearinghouse and enabling insurers and providers to share computer systems could save $55 billion per year.⁴

‍Resources

The NAM National Plan for Health Workforce Well-Being prioritizes addressing compliance, regulatory, and policy barriers for daily work. The plan recommends:

• Revise policies and requirements for documentation that do not contribute to quality patient care
• Focus prior authorization on supporting quality patient care while also reducing unnecessary burden on health workers
• Standardize licensure processes and re-evaluate mandatory learning and trainings
• Simplify interstate practice and virtual services

‍CMS Office of Burden Reduction and Health Informatics is advancing policies aimed at reducing administrative burden, such as requiring payers to implement an electronic prior authorization process, shorten the time frame to respond, and make the process more transparent. They offer resources for burden reduction, administrative simplification, and interoperability.

The American Medical Association provides research and advocacy resources on prior authorizations, including:

• AMA prior authorization physician survey
• Prior authorization state law chart

During COVID-19, the federal and state governments established emergency policies, including reducing licensing and credentialing requirements to support worker practice across states, in person and through telehealth. The Federation of State Medical Boards summarizes state telehealth policies.

‍Spotlights

‍In 2022, the Centers for Medicare & Medicaid Services (CMS) proposed new rules for streamlining the prior authorization including: requiring a standard, interoperable application for electronic prior authorizations, requiring certain payers to provide specific reasons when denying requests, publicly report metrics on their prior authorizations, and respond within seven days for standard requests and within 72 hours for urgent requests, and adding electronic prior authorization as a measure for Medicare’s Promoting Interoperability Program and the Merit-based Incentive Payment System.

Some states have enacted prior authorization reforms, including:
Pennsylvania’s law requires insurers to provide timely approval before services and treatment plans are rendered, ensures timely determinations on appeals, establishes a peer review process by physicians when insurers question a service’s necessity, and creates a single site for all electronic prior authorizations and paperwork to be submitted.

‍Texas passed a law in 2021 allowing physicians who have a “gold card” to be exempt from prior authorizations for certain services for which they have a 90% prior authorization approval rate over a six-month period.

The Government Accountability Office’s Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care lists policy options related to AI adoption for reducing administrative burden

The Health Resources and Services Administration (HRSA) funded projects to support licensure, including the Multi-discipline Licensure Resource Project provides licensure resources for occupational and physical therapists, psychologists, and social workers and is an example of streamlining and centralizing information about licensure.

‍ProviderBridge facilitated “passports” for physicians, physician assistants, and nurses to work across states during COVID-19.

‍References

1. CAQH. 2022 CAQH Index: A Decade of Progress. 2023. 
2. U.S. Health & Human Services Office of the Inspector General. Medicare Advantage appeal outcomes and audit findings raise concerns about service and payment denials. September 25, 2018.
3. Martin B, Buck M, Zhong E. Evaluating the impact of executive orders lifting restrictions on advanced practice registered nurses during the COVID-19 pandemic. J Nurs Regul. 2023;14(1):50-58. 
4. Cutler D, Sahni N. How to save a quarter-trillion dollars in health-care spending every year. Washington Post. November 11, 2021.