November 17, 2021

Episode 66: What keeps a healthcare economist up at night

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Description

Today’s episode is our last of season 4 and it's with one of the leading voices in the conversation around the nursing workforce. Dr. Peter Buerhaus is a healthcare economist and a Professor in the College of Nursing at the University of Montana at Bozeman. 

Today we talk about his research on the long-term impacts of COVID-19 on the nursing profession and some of the historical precedents that can give us hints at the future. Peter also shares what keeps him up at night, specifically how the constant negative messaging around nursing could ultimately dissuade young people from pursuing it as a career path.

Links to recommended reading: 

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Transcript

Dan:
Peter, welcome to the show.

Peter:
Hey, thanks for having me, Dan. I'm looking forward to it.

Dan:
Peter, I know you do a lot of stuff, and I think last time I heard you speak was at, I think it was the AONL Conference. You were talking about some of the latest research you've been doing on the nursing workforce. I know you're up to a million things, but what are some of the big projects you're working on right now?

Peter:
A couple of different things. One is that we're looking at immediate impacts of the COVID pandemic on the nursing workforce and then the longer-term impacts. On the immediate side, it's from an economic perspective. We're looking to see how has it affected the employment of RNs and LPNs and nursing aides in total and then in various different employment settings, hospitals, nursing homes, other areas. We're looking at unemployment as well. Has there been changes in the unemployment rates? And are we seeing any differences by age of the nurse? In other words, do we see any evidence that maybe some older nurses are leaving the workforce a little faster than what they had planned and/or do we see any effects that are related to a nurse's race or gender? And again, we're looking at various settings. That's one part of it.

Peter:
Second is we're surveying nurses themselves, nurse leaders, the leaders in most organizations, particularly hospitals, and we've also surveyed the public to see, are they more or less willing to recommend nursing as a career?

Peter:
And then the final part of this project is, this year, we'll be focusing in on what does all of the immediate impacts of COVID mean for the longer-term growth in the supply of nurses? Will we continue to see a growing supply, which we've projected, leading right up to the COVID, or will things change and we'll have less numbers of people going into nursing? That's one big project. And then there's a few others that we're working on as well, but that's the main one for nursing.

Dan:
Well, those are three huge questions to answer, and I think on the top of mind of everyone in the country, at least in the healthcare system about what's going to happen to the nursing pipeline. Do you have any preliminary assumptions that you're testing or any data that's showing anything interesting at the moment?

Peter:
Back in 2017, we published a paper in the journal Health affairs, and it projected, at that time, that we would grow the workforce by about a million nurses between 2017, 2018, out to 2030. This was a big relief because we were able to show that, numerically that is, enough millennials had come into the workforce to replace the baby boomers, and not only to replace this baby boom generation, and I'm talking about 1.2 million nurses that were born in the baby boom generation. We would be able to replace them and then grow the workforce by another million. This was really positive news in 2017. Recently, Dan, we updated those numbers, using data up through 2019, just before the pandemic started. And again, everything seemed on track. We're still going to grow this workforce by roughly a million over this current decade. So that's the good news, in terms of just before COVID, and it's now to then figure out will COVID disrupt those long term projections? And I sure as heck hope they don't.

Dan:
It's interesting. We did a survey of about a thousand nurses, and about 40% said they were less committed to nursing than they were before the pandemic. There's just these signals that are popping up that I don't know if nurses will leave it. I think they're questioning whether the traditional sites of care, where their passion is, the bedside hospital, acute cares. They're seeing so much opportunity in other areas, ambulatory care, telehealth, and others. I wonder if there's going to be a shifting of where nursing talent tends to go and prefer to work, and maybe it's not in the hospital. I don't know.

Peter:
Yeah. I think that's one big bucket of questions that we don't really have answers to yet. What will the workforce do? Some may leave and may leave a little sooner than they had planned, some of those retiring nurses. And I want to be clear that, when I said there were 1.2 million baby boom nurses, that is factually correct. But we've lost, over this past decade, about half of those, who've already retired. So we've got another, roughly 640,000 retiring nurses yet to go in the workforce. We know that they're going to go, one way or the other. It's just they could go sooner. That's one of those questions that is in that bucket that you were talking about. And then how is the workforce going to move around and shift around? And how are employers going to manage all that? That's part of that.

Peter:
What I'm concerned about is it has appeared to me to be this excessive negativity about nursing around hospitals that is just being reported daily or hourly or by the minute. It's about shortages. It's about all the difficulties that nurses are undergoing, the stresses and on and on. And it's just constant. You can't get away from it. And I'm not saying that this isn't real. But what I'm saying is that it is such a drowning out of all other messages that are getting out. And it worries, me that if it's not counterbalanced by positive messages, what we could see happen is people who are thinking right now in high school about, "Oh, I want to go into nursing, but given what I've been seeing over the past year, maybe, maybe not." Or parents, the same thing. "This may not be the profession I want to recommend to my child."

Peter:
That concerns me because if we should have a decrease in the entrance into nursing, that million nurses that I mentioned a minute ago that are projected to be coming into the workforce over the decade, may not occur. We need those nurses.

Peter:
You may remember, Dan, but you're a young guy, so you may not. But some listeners may remember this. Back in the nineties, this was the decade of hospital structuring and managed care. It was that time when the sixties, we had Medicare and Medicaid, and by the end of that decade, costs were going up, and spending was going up. The seventies, the Feds and the states all tried to regulate hospital costs and healthcare. That didn't work. The eighties was prospective payment and DRGs, kind of worked. Then we got into the nineties and said, "All right, let's try market competition, and we'll use HMOs to be that vehicle."

Peter:
Well, hospitals had to quickly lower their prices so that they could compete and get contracts with HMOs. And to do that, they decreased their employment of registered nurses, which annually had been increasing two to 3% per year in the early nineties. Now they slowed down that employment, but they let go a lot of the support staff around nurses, the aides, the orderlies and assistants and LPNs. RNs got very concerned about the impact on quality of care and safety. They went to the streets, and there were marches around the country, but particularly in Washington. They were loud, and they were vocal. Congress got excited. A new Institute of Medicine study was developed. This went on for several years. As a consequence, interest in nursing decreased sharply from about 5% of all freshmen students were thinking about nursing in 1995, down to 2% a few years later.

Peter:
The number of graduates started to plummet. In 1995, we had about 97,000 total graduates that year. In 1999, just four years later, it was down to 67,000. So the number graduating dropped by 30,000. It went on for quite a while. By 1998, we had a national shortage of nurses. By 2001, we had 126,000 open, vacant positions that hospitals were trying to recruit. That was our last large, big national shortage of nurses was way back in that 2000 to 2002 period, driven in large part by this decreasing number of people coming into nursing, having seen all these images.

Peter:
I today see that sort of same setup playing out. Those overly negative views could dampen people coming into nursing. That could take away all of those forecasts that we mentioned. We've really got to start controlling this message, being honest and truthful, of course. But let's start showing some positive images of nurses in the innovations and the things that they have done that are for the benefit of society and for their organizations, and be much more positive so that we can assure that we will have a growing supply of nurses in the future.

Dan:
Yeah. I think that's such an important point. I'm glad you brought it up and told the history because we can learn a lot from that. That message gets amplified. I had to delete Instagram the other day because I was on nurse Instagram, and everything is so negative. It's so bad, and it infects you. And you're just like, "Okay, I guess this is what nursing is now.: And you get frustrated. Then I go talk to my colleagues. We're like, "we can make change, but everyone's so sad at the moment." I think you're right. We do have to change that message.

Dan:
I was looking at one statistic, and it may be wrong. I think it was from the Bureau of Labor Statistics, saying we need 175,000 nurses through 2029 or something. Last time I googled the numbers, it was something like we graduated only about 150,000 in the US every year. Are those right numbers, or what's the current forecast in the next three or four or years for the need for nurses?

Peter:
Well, I stay on the supply side portion of that because the demand side is so difficult to forecast because you just can't anticipate so many things that affects the demand. For example, COVID. How do you really know that?

Peter:
Demand projections that are out there, I don't feel do a good job taking into account the aging of our population, the growth of dual-eligible beneficiaries, Medicare and Medicaid, the frail elderly, the lack of primary care that continues to worsen, not get better, the growth in behavioral health and mental health, and then maternal mortality. Just that set of examples I don't think are well covered in demand estimates. I don't pay attention.

Peter:
I watch the supply side because we're going to need a lot of nurses to take care of those growing areas that I just mentioned. I want to see strong growth in supply because the other factor, Dan, is we've got to replace those baby boomers. And yes, we'll do it numerically, but we've found, in this past six or seven years, that a new graduate just can't replace a nurse with 20 and 30 years of experience. There's just no way. We need to have time for that workforce to grow, to mature, to get fully up on its feet. All that is predicated on this growing supply of nurses. So I think I've evaded your question.

Dan:
No, it's good. The impetus for it, and this is a thesis that I've been developing, is we have good grasp of demand in the moment. We may not be able to predict out very far because of all the factors you mentioned, but we know there's X many thousand jobs out in the world for nurses at any given moment. Where I find struggle is we know the supply generally, but do we know in any given state, how many ICU nurses that are trained on XYZ that could actually come fill some of these roles? Do we have that granular data across the country on the supply side?

Peter:
Not across the country, but I bet you there's a few states that have really invested well in their data capacity and would probably either know that or have a pretty good working guess on that. But not in general, I don't think we have that kind of granularity.

Dan:
Do you think that something like that would be beneficial? Or if we had that granular data, let's say that National Council, state boards of nursing just created this unique nurse identifier. We have the MPI that's been out for a while. If we were able to tie a nurse's career path to a data set and know where they are, what they're doing, what their competencies were, do you think that would help us move the workforce around more efficiently? Or is it nurses just want to work within 40 miles of where they live, and they don't really do the whole, other than the small subset of travel, go out and find those matched roles beyond their local area?

Peter:
It's a really important question. My sense is you're probably right a little bit on the latter part. But on the former part, about having that data, I think we would benefit greatly from that because I think there are probably some opportunities to move the workforce through different incentives, to get the nursing workforce distributed where they're needed most. And we'll need some of this information too if we're thinking about a more diverse workforce as well. But I think even if we had had all this, the fact that COVID came in so hard, so fast, with so many really, really sick patients, the demand for these ICU and critical care nurses was just so high that it would've overwhelmed our supply, regardless. I think, in general, this is a good idea, Dan, what you're suggesting. But we have to be aware that we could have another surge, and it may not be of intensively sick patients. It could be something else. Will we be able to quickly pivot our workforce to better manage those insults, I think, would be benefited by having the data that you mentioned.

Dan:
Yeah. It's always been an interesting thought that if we had that, maybe there was some way to match nurses differently. But I'm also curious how you do some of this forecasting. What are some of the tools and methods you use to forecast supply and get down to the numbers you end up presenting and sharing, that really drive a lot of decision making and policy?

Peter:
I think the first big tool is working with really great people.

Dan:
That's always the first tool. That's the best advice you could have.

Peter:
I'm telling you, and I mean that by my colleagues, Doug Staiger, an economist at Dartmouth. He really developed the initial model, and it was somewhat influenced by Angus Deaton, who was an economist at Princeton and who had developed this model. Angus actually got a Nobel Prize as well.

Peter:
Doug was influenced by this and developed this model that looks at three effects, the population effec, which is how many people are out there in our population because the more people there are, the more likely there'll be more people who are interested in becoming a nurse. If there's fewer people, than less people interested in nursing.

Peter:
A second factor was over the age span of a nurse, do you see periods of time when they are more or less likely to be working in the workforce? This is really important for nursing since it's still predominantly made up of women, and women are having children and raising children. We've been able to look to see at what ages do you see a decreasing number of women in the workforce, and when do they come back into the workforce after childbearing?

Peter:
A third factor is what's going on in society that might promote people going into nursing? For example, when we were talking a minute ago that big, big national shortage of nurses back in 2001, this was bad. This was getting really difficult. It was the Johnson & Johnson campaign that was developed and portrayed nurses very, very positively. That turned a lot of people's minds to thinking about nursing. And then you had 911 back then, which caused, we found, older people - in their thirties, not old people - but older, in their thirties, to say, "I've been doing this job forever. I don't like it. I don't feel satisfied. I always thought about becoming a nurse. I'm just going to do it." And so they did. That helped grow the number of people coming into nursing.

Peter:
The idea is we're looking for changes in signals in society that causes people to become a nurse. Looking at the age effect, which is tracking their participation in the workforce over their life cycle, and then the size of the population. We put all that together, and we have decades worth of data. We're able to very precisely project the future using these three concepts. I don't mean to be bragging, but we've been really quite accurate in our models. We can predict things that were unseen at the time that the data would suggest. I hope that makes some sense.

Dan:
Yeah, no, that makes a lot of sense. And it's really helpful to understand all of those factors that come in. What are some of the interesting ways that that data's been used for some decision making? You've shared this with all kinds of people, you've published a ton, but are there some key decisions or key influences that you've had with this work that you're like, "Wow, I never thought that my model or our model could do X, Y, Z, or influence this thing?"

Peter:
Yeah, I think of maybe two big examples. One was when we first developed this model, we published it in the Journal of the American Medical Association. They took it, they published it. We projected, at that time, that unless things changed, we would face a workforce shortage, nursing workforce shortage, of maybe a half a million nurses by 2020. That would be five times bigger than any other previous shortage, and it would paralyze the workforce. That got Congress real, real excited, and ultimately, they passed legislation, called the Nurse Reinvestment Act, that threw in the weight of the federal government to grow the capacity of nursing education programs and student loans and things like that. That really helped provide incentives for new nurses, and it gave nursing education programs incentives to innovate and to try different kinds of programs to attract those nurses or those people in their thirties, et cetera.

Peter:
It also led to the private sector, the J&J Corporation, for example, based their Campaign for Nursing's Future on this article. And other state workforce centers were developed, about 35 in total, over the next 10 years. That piece of work was enormously effective in getting the production back into nursing and getting rid of all the negatives that were occurring in the nineties.

Peter:
Real quickly, the second piece that I think has come out is we've applied our model, that was built on nurses, to forecast the physician workforce. We've done two things there that I think were fun. We showed that some of these same effects occurred with physicians as with nursing. But the physician workforce people at a point said, "Women are 40% of what a man is, in terms of contributing into the workforce." So they said all these growing numbers of women physicians, it's not going to grow the workforce. It's bad news. We come along and show, "Yeah, but they come piling back into the workforce in their forties and fifties because of our work with nursing." And that really changed the whole dynamics of physician forecast, I think, for the better. That's a.

Peter:
But B, recently, a few years ago, we forecast a future supply of nurse practitioners and physicians in the country and of physicians working in rural areas. We showed a very slow production of physicians over the next 10 years. We contrasted that with an explosive growth of nurse practitioners. That, in turn, has caused policymakers to really focus a lot more on how do we take advantage of this nurse practitioner workforce that's growing, that's more willing to be in rural areas, now armed with data that shows, "Hey, this is where you want to invest your workforce dollars because if you do it if physicians, good luck because it's not going to get us the workforce that's needed to take care of society."

Peter:
A long answer, but two great, I think, outcomes coming out of that body of work.

Dan:
I think that's awesome. Those are both really at the macro level as well. I've just seen, through the whole pandemic, the same issues at the micro level of inability to forecast supply and demand and throwing money at the problem and trying to throw people at the problem. Part of it, I think, moving into the new world of technology-enabled care is nursing may look different, and we may not need the same number, and they may not, not be in the same work. So I've been trying to push our nursing colleagues to let's not double down on the past. Let's learn from it and figure out what the future is because Blockbuster doubled down on the past. We all know what happened to that company. Nursing needs to use the data and the evidence they have and jump off of it into the future.

Peter:
Totally. I'm with you, Dan. And I would also say that what's exciting is that I think hospitals, particularly, but other organizations want to do it too. I don't think they want to go back to the past.

Dan:
Yeah. They don't want to go back to the nineties.

Peter:
No.

Dan:
And all the shortage and that kind of stuff. Yeah. What are you most optimistic about for the future of nursing?

Peter:
I think what has been stunning and amazing to me, and it gives me pride as a nurse because I'm the nurse on most of my research teams, is to be able to show, through various sorts of data, how strongly the public feels about nursing in terms of trust, in terms of respect and admiration. It's been this consistent positive recognition. You know and listeners know the yearly Gallup polls that are done in December, and they show that, time and time, about mid-eighties percentage. 85 or so percent of the public feels very positively towards nurses. It's 20 points above what physicians are. It's not a little bit more than physicians. It's a lot, and that's been consistent.

Peter:
They also trust nurses more than any other profession or organization to improve the healthcare system. This was found in a big Harvard, Commonwealth, New York Times-funded national survey of the public back in the fall of 2019, before pandemic. In it, it showed that the public was 30 percentage points more likely to say they trusted nursing to improve the healthcare care system above that of physicians.

Peter:
As a consequence of this strong public support, we've had many, many foundations and federal and state governments invest in nursing. Well, I've mentioned the J&J program that started in 2002. It's a new initiative that started a few years ago. But the Robert Wood Johnson Foundation has spent, I bet you, it's getting close to a billion dollars on nursing over the past two decades. The Gordon and Betty Moore Foundation on the West Coast, the Macy Foundation educated 10,000 nurses. All of that and much more has come to nurses because of this positive perception. I know of no other profession who can even show anything near that.

Dan:
You're right. There's so much support for the profession in all of these different factors. Despite all the negativity we talked about, it's still an amazing opportunity to impact the world and people's lives and do good and actually really change entire communities and populations. You mentioned all that. It's that nursing is this bedrock of the United States and many other countries, and we have to continue to shine a light on it and show all the amazing ways that people can come into the profession and change their communities for the good.

Peter:
You said it better than me.

Dan:
Well, the host just summarizes. Well, we like to wrap up the show with a handoff, what is that one nugget that you want to pass on to the listeners? Peter, I'd love to hear what you'd like to hand off.

Peter:
I would say a couple things. One is the message let's be careful with that. We don't want to wreck what looks to be a positive decade of growth. We're going to have a lot of change coming in, and I'm optimistic about this change will be for the better. But we do need to grow that workforce, and we need to get seriously positive. That means all of us. So that's one piece.

Peter:
One thing that we didn't discuss, Dan, but it's on my mind is that, as we move into this new decade, post-COVID, we're going to really have to get very, very familiar with value-based payment. That has been put on the back burner, if you will, given COVID. But pretty quickly, that's going to be inside nurses' world. And it's not something that the hospitals or other organizations do. We've got to understand it and take advantage of it because I think this is going to create a very new and positive economic relationship with our employers.

Peter:
Maybe we can do that another conversation. But I think that's the one that people really need to start thinking seriously about and getting prepared for.

Dan:
Yeah, that last one, I think, is so critical, and let's get nurses out of the room charge and actually reimburse for the value they add to the system and all those types of things that can really change the game and how workforce is built and how nurses are staffed and all kinds of different things. I think that's the critical conversation. Yes, we'll have to do another show maybe when we get into that. That'd be fun.

Dan:
Well, Peter, it's been awesome to chat with you today. Thank you so much for being on the show. Where's the best place for people to find more about your research and more about you if they want to learn more?

Peter:
Well, they could probably ping me. That would be the best way to go. My email address is Peter.Buerhaus, B-U-E-R-H-A-U-S, @montana.edu, and be happy to correspond.

Peter:
But Dan, thank you. This has been fun. I've known you for a little bit, but this is a good time to have a great conversation. And thanks for doing what you're doing.

Dan:
Yeah, no, appreciate it. Yeah, it's always awesome to just have these conversations and push the walls a little bit. So with that, take a look at Peter's work. There's tons of articles we'll put in the show notes as well.

Dan:
And yeah, get out there and change the message. It's got to be positive. We got to get more people into nursing, and this is the profession that's going to change the world. So let's do it.

Peter:
All right-y. Thanks, Dan.

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