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Does the US need a National Guard of nurses?


Dylan Matthews and Dara Lind are joined by Vox senior correspondent Dylan Scott (@dylanlscott) to discuss the shortage of nurses in the American health care workforce. The nursing shortage goes back many years, and not only did the pandemic exacerbate the problem, it also put it under a microscope. The US needs more nurses, but what can be done? 


America needs more doctors and nurses to survive the next pandemic

The way the United States pays for nurses is broken


Dylan Matthews (@dylanmatt), senior correspondent, Vox

Dara Lind (@dlind), Weeds co-host, Vox


Sofi LaLonde, producer and engineer

Libby Nelson, editorial adviser

Amber Hall, deputy editorial director of talk podcasts

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This is an unofficial transcript meant for reference. Accuracy is not guaranteed.
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- Hello and welcome to another episode of The Weeds. I'm your host, Dylan Matthews, and today I'm joined by our regular co-host, Dara Lind. - Hello. Dylan Scott, a senior correspondent at Fox, covering healthcare and arguably the best Fox senior correspondent named Dylan. It's a vicious debate in the newsroom. Many people are saying. So today we're going to be talking about a long-standing issue in American healthcare and one whose sort of costs and burdens have become increasingly pronounced as the pandemic Which is the shortage of healthcare workers. You've probably been hearing about the nursing shortage for many years. I remember hearing about that maybe in the mid aughts.
That's been going on a long, long time. But the US also has various policies that artificially limit how many doctors can practice. It has limits on what specific categories of health workers can do, what you can do if you're a medical assistant versus a CNA versus a nurse versus a nurse The physician's assistant, and on and on through all the many different acronyms. You just wrote about this and in particular about sort of our inability to surge health worker capacity during pandemics. So could you walk us through sort of like the basic contours of the problem as you see it? Yeah. So I think there are like two sides to this coin. There's the public health side and then the clinical side. So the clinical side covers a lot of what you just described. Like we have shortfalls with nursing staffing and we have just all these regulations and rules that limit both, yeah, the number of...
Medical personnel that can practice, but also the kind of services that they can provide. And you know, during normal times, hospitals have kind of every incentive to staff themselves at sort of like maximum efficiency, you know. There's no money to be made in maintaining a surge capacity when there's not a pandemic. And arguably, you know, we wouldn't necessarily want them to because that would only kind of artificially keep costs even higher than they already are. But like there was obviously a very. Limited ability to create surge capacity, which I'll get back to in a moment. But then on the public health side, that is a place where we've also... Like really underinvested in the human infrastructure there. So like over the 10 years before the pandemic happened, local and state health departments, which are obviously kind of the core of the public health system that exists in the US, had lost like 15%.
None of their staff over that period. So we started this situation with sort of a dramatically underfunded and understaffed public health system. You know, there've been some attempts to kind of quantify the problem. And there was an analysis that came out that estimated like. If we wanted to properly staff state and local health departments just to provide sort of the bare minimum public health services that we would want them to be able to provide, we basically would need to double their staffing. So like we currently have about 100,000 of those workers. 180,000. So like on the clinical side, you know, we're kind of running at maximum efficiency all the time within all these kind of restrictions and limitations that are placed at like the state level especially with rules about scope of practice or at the federal level about like you referenced, you know How many doctors can kind of enter the pipeline to get into the medical workforce and then on the public health side? We just had been you know chronically underfunding
Understaffing those kinds of activities. So we were compromised from the start, but then once the pandemic happened, there was-- not really the ability to create, you know, to surge our medical workforce either. So like we do have a couple of pre-existing programs that are meant to provide some kind of search capacity. There's the Public Health Service Commission Corps, which is like uniformed officers. There's about 6,000 of those. And actually like in normal times, Half of them are deployed to the Indian Health Service. So it's not like those people are just like sitting around waiting for a pandemic. Like if we redeploy them. Somewhere in the country because there's a public health emergency that's leaving behind marginalized communities that are going to have less health care access as a result. Also, the Medical Reserve Corps, the number of people involved in that is about 200,000 people, but like it's an entire. Voluntary program from talking to experts on this kind of thing.
Implementation varies really widely across the country. It ranges from like people who are clinicians or public health professionals but it's also just like laypeople who maybe want to get involved because this is another program local level. And you know, for some of them, like all they could really do was like staff call centers and that kind of thing. You know, some of them are like, yeah, we're going to do a call center. And then, you know, we're going to do a call center and then we're going Them did help with like contact tracing or with setting up testing sites and that kind of thing and you know... Even in a place like Seattle, Washington, I talked to Betty Beckmeyer, who's a professor at the University of Washington and studies the public health workforce. There where they have like invested quite a bit in their medical reserve core over the last, you know, five years or so, it still wasn't sufficient for what they needed. It for COVID. So we had both like in terms of kind of the infrastructure, we hadn't been investing enough in public health and And just the way we run our healthcare system doesn't create a lot of incentive to create surge capacity on.
The clinical side, and then like we just didn't really have the programs or the protocols in place to dramatically surge our healthcare workforce when something like COVID-19. And you know, I mean, to be fair, like we'd never really stress tested our system like this before, you know, there were all these kinds of assessments of like public health readiness before COVID and like the US always ranked at the top of those and so like you know you kind of don't know what you aren't capable of Doing until you're put on the spot like we were. But if there's any-- small silver lining of what's happened over the last two years, I think it's become evident to everybody what it would take. To be able to marshal a more adequate response if this were to happen again. - So I have a bunch of questions. Most of which are super elementary. And like, Dylan, because you, Dylan Scott.
Because you distinguished between the clinical and public health sides of this, I'm wondering what does the public health infrastructure on the ground look like? Does it really look that distinct from clinical infrastructure? Is it a different kind of workforce that would be needed? Like, why is that a different face of the problem rather than just like a lot of institutions pulling from the same very depleted pool. Public health is like your local health department, your state, especially your local health department, like you know, three fourths of the public health workforce is de- Employed by local governments. And so they're doing things, you know, especially in normal times, you know, they might be running like, you know immunization clinics You know, they're they've respond, you know to smaller more acute outbreaks like if there's a local measles outbreak that kind of thing. And you know, so they're trained more in like those kinds of preventive activities, you know, responses to disease outbreaks specifically, you know, your MPHs, those kind of folks. And obviously that was a really important need.
During COVID and like, you know, we do do like contract tracing in normal times, though largely for things like STDs. So like that's what some of those folks are trained to do. On the clinical side, you have like your nurses, your RNs, you know, your nursing assistants and you know that whole, you know, alphabet soup of various staffing roles in like hospitals, especially. People would be tasked, in my mind anyway, with like, you know, disease surveillance, maybe setting up testing sites once we had vaccines, setting up vaccination clinics, that kind of thing, performing contact tracing, certainly. Then, you know, obviously people are getting sick, you know, ending up in the hospital. And so then you had the clinical need there of nurses who know how to administer medications and monitor patients for deteriorating condition, that kind of thing. So those are the kind of why I think of those as sort of like two distinct but related buckets.
So we mentioned health departments at the county or state level earlier. We've certainly heard more. About those lately than in a typical year since 2020 or so. I'm still sort of not fully up to date. Today on what their responsibilities are vis-a-vis the CDC or individual hospitals or things. So can you walk us through the role those play in the system and what role they've played as the pandemic has played out? - Your local health department is like the front line. Of public health. Like they are a lot of the responsibilities certainly before COVID and even during COVID for the kinds of things that I was talking about, like chronic disease management, immunizations, those sorts of things are delegated to the local level. That's why like three fourths of the public health workforce is situated in local government. And I think that gives them like a lot of discretion and autonomy about how they want to run their programs
You know, one step up. You have state health departments which make up about another fourth of the the workforce and you know, they They help kind of set like slightly higher level kind of priorities and programs. Certainly they can be deployed in acute emergencies. To help the local health departments. And really at the federal level, like the CDC. Is primarily in my mind kind of like, it's a guidance making kind of operation, you know. They are certainly meant to kind of, you know, take a more holistic national picture, but like they don't have the same kind of capabilities to set up testing sites, to set up vaccine clinics, contact tracing. Like their role is much more to kind of assess like what's On with the pandemic, what would be sort of the best policies for trying to mitigate its impact. but like as...
The Biden administration and the Trump administration ran into time and time again, like they can say like, this is what we think people should do. This is what we think the guidelines should be. But state and local governments have a ton of discretion. About whether they really want to follow those guidelines. - It seems a lot more like car talk than AAA. It's like you call the CDC, they tell you how to fix your transmission, but they're not gonna go to the side of the road and do it for you. - They're not gonna send somebody out. - Exactly. Um... something that- Help me a lot in understanding these health departments is an obscure writer named Michael Lewis. A little book called The Premonition and a lot of it is about this woman, Charity Dean, who ran the... Health department in Santa Barbara County. And it was funny in that like she-- It's a very vague position and so she had all these powers she could use like like Quarantine and people if they'd been exposed to the perky losis, but precisely because it's vague which County uses it which way seems wildly
- Right, yeah, exactly. And this was certainly another place where like, there were big disparities across. States and regions, like you know, there are certainly places like Washington State I think is held up as an example of a place that has invested a lot in public health over even, you know, before the latest emergency, but like, you know, especially with the lingering effects of the Great Recession on state and local budgets, and certainly I think there were parts of the country that just didn't see this as a point of emphasis. And so I think that also compromised a lot of places' ability to respond. The other question I have to kind of get my head around this is about skills, right? That the Reserve Medical Corps may not have been trained in contact tracing, you know, that kind of thing, but it does seem like, you know, things like contact tracing, setting up vaccination clinics, are not super difficult.
To acquire skills. Those are trainable, like in a fairly short amount of time, certainly compared to like being a doctor. Or nurse, both of which are, you know, extremely like credential gate kept professions that unlike a lot of other credential gate kept professions, there isn't. A whole lot of like, no one is really pushing to abolish the MD requirement to practice medicine. So it does kind of seem like we're talking about, you know, on the public health side, a problem of workforce that like may not be Ideally sufficiently trained but where there's like where you don't have to worry that you don't have exactly the right credentials of people but on The clinical side, it seems like a much harder problem because how do you have a reserve of people who have nursing skills and have bothered to invest the--
Time and money into acquiring them and aren't using them on a regular basis. - Yeah, no, on the public health side, I think it's much more just a matter of resources. Like, yeah, you can train people, I think, relatively quickly to do things like contact tracing. It's just a matter of having the money to hire them and train them. And that's where I think the shortcoming-- has been most in public health. Yeah, on the clinical side, you know, we have things like, you know, the limited number of residency spots that exist for doctors. You know, we have caps on like how much we're willing to kind of... Reimburse nurses for their educations, those kinds of things. And so that I think, that's a space where like yeah, you can't just suddenly create 100,000 doctors or nurses. I think there are certainly things, and I know we'll talk about it, that you can kind of do pretty quickly to at least like maximize what you're getting out of the medical workforce that you have.
Have. But then there's also a question of like, yeah, how much do we need to be doing to actually like grow the medical workforce, both so that it can better serve people all of the time, but also so that we have some kind of capacity to respond to. To an emergency. I was actually talking for a different story about things related to this. And he made the point to me that like, we do have like a lot of nurses and this is probably true of doctors too, though we were talking specifically about nurses who have gone through the training, who have acquired those skills, but they have like left the profession for whatever reason, which is. Obviously, you know, staff burnout and retention is sort of its own, its own element to all of this. But like that does speak to like, there is arguably some, a surge capacity to tap into, but it's about having like the protocols and programs in place to tap into it because it's not like you can just suddenly, I don't know what you would do, like post something on
on Facebook and say like, Hey, all you like not practicing nurses, could you like come help us out? Like you needed a little more formal process than that. On the other hand, like you can totally imagine, you know, there being legit civil liberties concerns If Congress were to pass a law saying once you retire from the nursing profession, you must add your name to the former nurses registry Right, right. Yes, there might be some 13th Amendment issues, right? Sure But like, you know one of the ideas that was floated by me was the idea of like a kind of nursing which certainly, you know, to your point would be on like a voluntary basis, but what the idea would be to kind of keep people tethered.
To the system, you know, maybe much like the National Guard does, you have kind of periodic trainings or something so that people can keep their skills fresher. But to your point, kind of a reason that you want to have sort of like well-constructed capabilities to tap into that rather than like either just not, which certainly seems like a wasted opportunity after what we've seen over the last couple of years, or trying to do it on the fly in the middle of an emergency. We're going to take a quick break, but then we're going to talk about some policy solutions to our health worker shortage, like the Reserve Corps we were just talking about then. So stay with us.
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Sort of setting the reserve core aside for the moment, what are some sort of like permanent clinical things since we do have some constraints on sort of how many people are just like. Practicing in hospitals and private practices and the whatnot. Right. So yeah, like Congress literally, uh, through a mechanism in the Medicare program, like. - That's a number on how many doctors can enter the medical school pipeline, and even down to what specific specialties pursue. I mean one thing that has already happened is Congress has approved like an additional 500 primary care residency slots. And so, you know, that is one way in which we can more permanently expand the medical workforce and hopefully kind of or tailor it, you know, both in general because like, you know, we don't need to get into like the value of primary care right now, but like certainly when you think about like what you'd want in a pandemic.
Response scenario. Certainly when doctors who maybe specialize in infectious diseases but then just primary care is obviously going to be people's you know usually their first point of contact you know if they get sick or you know one need to be tested or vaccinated or what have you and so having you know more Mary Care doctors certainly seems like it would be worthwhile. Nursing even I think more so than doctors is another place where the argument was made to me that like we could invest a lot of money in that. More. I was made aware of the enormous discrepancy in federal spending on MD doctor education versus nursing education. I believe, I don't have it pulled up in front of me, but I believe We spend about $15 billion a year on doctor's education and about $250 million. Million dollars a year on nursing education. And you know, this goes back to, this is actually a piece that I'm working on now, kind of a fundamental.
Whole problem in how like we value nursing because like you know if you go to the hospital you don't really get billed for like what the nurses do like they don't generate a right they don't generate revenue for the the hospital but the doctors they do because you know they can bill for all the services that they you know the services that they provide are literally just like their time and so like that's sort of a longer conversation of how we might better value nursing and how we pay for health care but just more straightforwardly like we could invest a lot more money in and educating and training nurses and likewise certainly on the public health workforce side I think as we've already covered like there's a there's a good argument
That there's a tremendous shortfall on how much we're spending on our public health workforce. So those are sort of like I think structural changes that a lot of the experts I spoke to for this story would like to see made, you know, but then there are certainly things that we could do that are more like flipping the switch, you know, training more doctors and educating more nurses is a long-term project and we don't know at this point, you know, when the next public health emergency might occur. So you know there are things like scope of practice limitations that you could change. So like you know every state is different but states have rules about like you know doctors are allowed to do this you know with. This level of certification and nurses are allowed to do this, you know, under, you know, maybe it needs to be under a doctor's supervision or not. And so one of the things that that would be pre-
relatively easy to do and we saw in kind of a patchwork way during COVID is like relaxing some of those restrictions. To go back to what I was saying to Dara, like that's a place where it's about maximizing the healthcare workforce that you already have. So if you let doctors do more somewhat beyond what they might ordinarily be allowed to do with their licensing or if you allow nurses to do things like prescribe medication because like they can see with their own two eyes that like the patient needs X and like you know they have enough training and experience to be able to make it through. That assessment. There might be reasons that ordinarily we don't allow them to do that but like you know when you're trying to get the most out of your hospital staff maybe it's time to relax some of those rules. We have other things like, you know, there are certainly like retired doctors, you know, we license doctors on a state by state basis, maybe, you know, a doctor. Has moved from one state to another and is no longer practicing, maybe somebody moved from another country and has a foreign medical license but hasn't gotten
Licensed here in the United States, relaxing some of our licensure and certification requirements for those folks would be an easy way to get more medical workers out in the field in the middle of a pandemic. Even like, you know, somebody made. The point to me that like the senior year of a nursing student's education is like electives like leadership and that kind of stuff, which not to be, you know, not to diminish the importance To those kinds of things, but like they've had all their clinical training already, right? So like, maybe we should, in an emergency situation, we should license those people to go out and start actually practicing up to the level of training that they've received. But with that kind of stuff, with like scope of practice and some of these licensure changes, like maybe half of states did that during COVID. Maybe less than half, I think, with some of these things. So it was very much kind of a patchwork response. And so I think what experts would like to see going forward is both like a--
That these things are valuable and can help us, in a pinch, expand our healthcare workforce's capabilities, but also as part of that, we need more uniform adoption of these kinds of policies. It's definitely kind of a two-step of like, how can we, yeah, how can we both increase our Our short-term ability to respond, 'cause who knows when the next outbreak's gonna happen, but then how can we invest in the healthcare infrastructure in a longer-term way, just to create a more capable staffing. The medical education gap that you identified and like I'm sorry if I'm gonna force you to scoop yourself because I know you mentioned you're working on a piece about this but like it seems plausible to me that part of this gap might be that like Universities as a whole, medical schools are serving both as training centers and research centers, right? And so there's an argument that money that you're putting
into medical schools is potentially going to be generating new medical knowledge, whereas as you know. Nursing and public health programs tend to be seen as professional certification programs, right? Where you're just doing the education function like, you know can't you turn a nursing program into something that's also going to generate knowledge or is this just a matter of we need To do a better job of understanding that like the amount of money being poured into medical schools is way disproportionate to the extent to which they're generating knowledge as well as human beings? - That's a great question, and I don't have a good answer on the research side, though I'll maybe circle back and ask. Some people about that now. But I do think maybe as fundamentally, there is just the problem that I was describing before of how we value nursing.
You know, if we don't value nursing and like how we pay for health care, basically then like there's hospitals are making economically rational decisions to minimize their nursing staffing which obviously sort of Puts a downward pressure on the pipeline too, right? because like there are only so many jobs available and that's just gonna kind of self limit how many people The field. And so I think, you know, imagining ways that we might better value nursing through how we pay for healthcare would arguably be one way to like to help to balance that that kind of mismatch that you described. It could be that like we could like generate more like medical knowledge or what have you by investing in more in nursing.
In public health. But I think there's also like kind of a value proposition there that could be made, you know, but it would require, you know, reimagining to some extent how we like, yeah, pay for healthcare and those kinds of things. - This is perhaps like a little too far afield since solving the issue of ours. Supply of health workers is perhaps enough to bite off. But we passed a whole law in 2010, whose whole point in part was to sort of change and sort of move away from fee-for-service. Did Obamacare wind up doing much there? It seems like we're having the same kind of conversations about the same perverse incentives around fee-for-service that we were having in 2000. I have to say one thing before I answer your question, which is I learned in the course of reporting this story that Obamacare actually created what was called the Ready Reserve Corps. It was going to be kind of like an offshoot of the Public Health Commission Corps that I referenced before, but this won't surprise either of you because
Of like a technical error in how the law was drafted, they didn't set aside the funding for it. And you know, obviously like once Republicans took over, one house. Of Congress, any new funding for Obamacare was dead in the water. So that program just sort of languished, you know, existing on paper only for 10 years. Though as a part, to Congress's credit, as a part of the CARES Act, they did finally set aside funding for it. I believe I saw like early last year, they finally started staffing that up, but like we started staffing. - It up almost a year into COVID. This program that like had existed on paper for 10 years, but we had just failed to put any resources. Into. So anyway, that's one way in which Obamacare failed us ahead of COVID. But the as much as the affordable was built into the name.
In the branding and how the Obama administration and Democrats frame the law. Largely it has funded like pilot programs, right? Like accountable care organizations and other programs run through the Centers for Medicare and Medicaid Services meant to kind of reimagine how we pay for health care, figure out ways to to pay for value instead of volume and that kind of thing. And like, I think there's two things. Have kind of limited the impact of those programs. One is like, they were pilot programs that like did not really kind of create any like long term, like, well, if this works, then like we're gonna change how healthcare is paid. For in the United States. Like it was just sort of, we're gonna run a bunch of experiments and we'll see how it goes and like we'll kind of come back to it later. Of it is that I think the results for most of those projects have been kind of mixed. ACOs, I know specifically, it's been like, well-- You've saved some money, I guess, and quality seems a little bit better, but it hasn't been some kind of like...
Resounding success that like was impossible, would have been impossible for Congress or future administrations to ignore. And you know, 'cause fixing healthcare obviously is really hard. So it was more of kind of a first step down the road to, I think. Remaking or reimagining how we pay for healthcare, and for a variety of reasons, both because of just, you know, the limited scope of what the ACA actually authorized. And a limited ability of what we've tested so far to actually deliver that kind of promise of better care for a lower cost, we are still largely in the same place that we were 10 It sounds like the same kind of problem that government pilot programs often have, which is that their determination to actually help people and therefore stay within already accepted best practices, they are not as complete a break with like...
The existing state of knowledge in the field as they should be. It makes a lot of sense, especially in the healthcare context, that if you're at the Centers for Medicare and Medicaid Studies and you are trying to figure out which pilots to pour money into, you're going to be going with the things that are most important. Likely to succeed, but the point of running this kind of pilot program is to demonstrate success. Where success might not have been expected. And so, you know, that means that you essentially... Have to have grant authorizers who are like, I don't care if people don't get the care that they would under a more conservative program because we're trying to see what happens in the weird event. That they do. Yeah, well, and like to your point, as soon as you start setting up these programs, you start making compromises, especially because of the influence of the health industry. Well, I think it was with ACOs, or one of the similar models that they set up. I think the most ambitious version
would be like, well, if you deliver really shitty healthcare, then you're gonna lose money. We're gonna actually penalize you for delivering really shitty healthcare. As those programs were actually like being drafted and they started entering negotiations with healthcare providers about how they set them up, a lot of that downside risk started. Get eliminated, you know what I mean? And so it became entirely sort of an upside. Like if you do like, you know, hit certain benchmarks or certain quality targets. It's like, you can make more money. It was a lot of carrots, but the sticks were kind of. Slowly whittled down over the course of actually setting those programs up, which I think speaks to the problem that you're describing. I want to ask a little bit about the commission core. So like this is something that's, that's confused me for a long time. Long time and now I have you here and I can ask annoying persnickety questions about it. I hope I can answer them.
Uh, but yeah, like the analogy that seems to draw us to like the military. And if I want to join the Marines, like they would probably say no because my fitness is dog shit. I can walk into and join the Marines. My sense is that the commissioned corps doesn't really work like that. There are higher bars of entry and there are only specific things you can do in it and it's also just dramatically smaller. Than any of the armed services. Like, what is the kind of health of that, and are there plans you've seen to try to reinvigorate it? seen it be a point of emphasis in terms of like what we could do next or what we could do better going forward. It has actually like shrunk in size. Some degree over the last, I don't know, 10 to 20 years. It used to be about 10,000 people. And now I think I said before, it's more like 6,500. So like, it's not been a point of emphasis. I think that's probably partly the barriers of entry that.
You're describing. And so, you know, they did step up and finally fund this Ready Reserve Corps, which is kind of a piece of the Commission Corps. Like, maybe, this is just me guessing as much as anything, but like, given how essential it has become, I think specifically to the Indian Health Service, like I said before, like, About half of the commissioned corps, you know, in non-emergency times is deployed to those sites to provide healthcare. Like, I just don't know if... It's seen as sort of a particularly effective avenue. Like it's telling I think that. The Biden administration, after President Biden was elected, came in saying like, they're not talking about like expanding the Commissioned Corps. They were talking about like, we need to create a new 100,000 person public health workforce. And so like, you know, maybe partly because it's, you know, they don't want to continue going down the quasi-military path, maybe because of the way that those people are already being used. I think it is just sort of, you know, it's an
And it just doesn't have the kind of scale that we would need. - Why is the answer to create more different? Through national service programs, like it seems like there's like an alternate path where the decision is just made to invest in AmeriCorps to staff up exactly these positions, right? Unlike it does seem that if you're talking about a surge capacity in particular that having a workplace Force that is largely like young people who have undifferentiated skills but a lot of eagerness that that might be the right answer. Actually talking about things that are fairly specialized in practice and so that's not, you really do need to create a separate pipeline where people Who already have those skills coming in can be deployed? Or like, is this just government looking at a program that isn't doing
everything it can and saying we need to create a new one rather than saying we need to improve the existing one. I was going to say, I don't think I have like a great answer, but obviously as you well know, like the value of a shiny new object in politics as much as anything can sort of Overstated. Because yeah, I think like especially with the public health side of it like as we were talking about before like certainly you need like some training to be able to perform some of these functions but like it's not like you need four years of nursing school that kind of thing. So, you know, I think there's certainly an argument that we could do more to just kind of utilize. Of the kind of public service workforce that we already have, then on the nursing side, like that's, you know, certainly I think an argument for a more kind of specialized unit, like this nursing reserve that.
Betty Ramboer at the University of Rhode Island pitched to me. Like I was saying before like we do have both obviously like people who are already currently working as nurses, but then also an even wider circle of people who have at least been trained as nurses even if they're doing Something else right now. So you know, but that is like I started off talking about this, how there's kind of two sides of this coin. And I do think the public health side in a way is easier to fix because I think it's just a matter of resources like the barrier to entry is not necessarily that high in terms of skills or that kind of thing. The nursing I think is a little more like, goes more to sort of the heart of some of the problems of American healthcare. Which are much naughtier to try to untangle. - All right, having solved the workforce problem, I think we're gonna have to take a second break and talk about yet another problem in the American healthcare system, particularly high prices and what, if anything, they can buy for us, so stay tuned.
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The best version of yourself. Visit MethodProducts.com to unleash your inner shower. Shop MethodProducts.com. Welcome back to another video. Welcome back to another video. Welcome back to another video. Welcome back to another video. So this week's white paper is titled, Do Higher-Priced Hospitals Deliver Higher-Quality Care? The answer is sometimes. So the authors here are economists Zach Cooper, Joseph Doyle, John Graves, and Jonathan Gruber of Obamacare fame. They find that higher-priced hospitals do, on average, have patients with fewer deaths. So in that sense, the answer is yes. And they have a pretty interesting-- That they're using patients who were picked up by ambulances, by private ambulance companies. And the companies routed different patients to different
hospitals semi-randomly. And so the main differences between the patients were just that they went to different hospitals, as opposed to one hospital just happened to get richer or healthier patients or something like-- Out that would confound the results. But-- - Just to say, this experiment is based on the fact that if you're being picked up by an ambulance, you don't actually get to control which hospital-- you go to. I forget who it was that said that behind every natural experiment is a massive policy failure. This is definitely the Oregon Health Study. There's a lot of really grim policies that have led to interesting research. But the big X factor that the paper seems to find is sort of How much competition there is in the hospital industry, whether there's just a couple of big hospitals or just one big hospital or a number of hospitals that are competing against each other.
If there is lots of competition, it seems that higher prices do lead to higher quality, that mortality rates are lower among patients who go to those hospitals. Concentrated area where there isn't competition, you're not buying much of anything. So, Dylan Scott, what-- you make of this overall, and how does it fit into your overall understanding of what we know about paying for health care and quality? Fundamentally, it just goes to that idea that like, in a lot of places in the United States, there is not a strong incentive for hospitals to provide quality care, especially if they have grabbed up so much of the market share that you don't have any other options. We have just not. Structured the way that we that we pay for health care in a way that incentivizes those health systems to focus on the quality of care that they're providing. On the other hand, it certainly makes a bit of a case that the market can provide some of that stimulation.
But like, as I think, I can't remember, I don't have the number right in front of me, but you know, they make the point that I think it's like, close to 70% of like the markets in the-- Care markets in the US are highly concentrated. So like it's much more the exception to be in an area that has robust healthcare competition that is propping up quality in the way that they describe. And it did make me think of this. Nursing story that I've alluded to that I'm working on and this idea of because like The idea there is like obviously nurses like improve quality, not obviously, but like it has been found that healthy nursing, like nurse to patient staffing ratios, that kind of thing, increase the quality. Of healthcare, but because there is no like revenue to be generated out of. Employing more nurses, hospitals still tend to minimize their nursing staffing as much as possible. So like you can imagine a scenario with like with these hospitals where it's like if you're in a competitive market
then maybe you do make some of those investments because there is like a kind of economic gain from investing in those kinds of things and generating more quality care. But as the kind of core finding of this paper finds, like if there isn't that kind of economic incentive for a hospital to make those kinds of investments, then why would they? 'Cause like, as you're saying, Dara, like ambulance picks you up and if there's no other hospital to go to, like that's where you're going and you're gonna get the care that you're gonna get. And there isn't really anything pushing the hospital other than like altruism, I guess. To try to do better by you. - Even when there is an effect on mortality, I have questions about like the effect size here, right? Because they're saying that like an increase in-- two standard deviations in expense, increases spending by 52%, and lowers mortality by 1% point. And 52% seems much better!
Bigger than one percentage point? And I understand-- - They're percentages of different things, but yeah. - Yeah, no, no, well this is kind of my question. Like, I definitely understand how mortality is a very big downside. Side risk, right? But what I don't know, because I don't understand the industry all that well, is how well does Mortality track with other health outcomes. Like if you're not being admitted for a genuinely life-threatening thing, badly enough to kill you, then is a hospital that has a lower mortality rate in more life threatening circumstances also likely to provide you with better care? And more of an upside than an inferior hospital or those pretty different things. One of the more interesting numbers within the paper is that in sort of not very concentrated markets, the ones where there's decent competition between hospitals, each life saved...
Comes from another like $1.09 million in health spending. They point out that the federal government for all kinds of regulations has this thing called the value of a statistical life to figure out. You know, as Homer Simpson once said, you know, Sure, we could make the speed limit 55, and sure, some people would live, but-- More would be late. To make decisions like this we use this value of a life number to weigh against economic costs. The EPA is about 8.7 million. So this is a lot below that. And so by that standard, this health spending seems to be-- Find something that the people are willing to pay for. At the same time, I-- I also come from a context of writing a bit about global public health and... Of like malaria interventions, like four to five thousand dollars per life saved is considered a pretty good number. And so it's not exorbitantly expensive, it's probably worth it, but it's not like the most cost-efficient public health.
Intervention you could imagine either is sort of where I came down on that. And again, that's only for these hospitals in relatively competitive areas. You're in, say, a rural area that can only sustain one hospital, and they increase their spending. It's not clear to me how much you're going to actually get out of that. Yep. That is all for us today. Thank you to Darlin and Dylan Scott for joining the panel and for everyone listening for dealing with the fact that we have two Dylans. We made it through. I think it was not too confusing. Sophie Lalonde. Libby Nelson is our editorial advisor. Amber Hall is the deputy editorial director for Talk Podcasts. And I'm your host, Dylan Matthews.
Media Podcast Network. www.mooji.org Copyright © 2016 Mooji Media Ltd. All Rights Reserved. No part of this recording may be reproduced without Mooji Media Ltd.'s express consent. It's summertime, and whether you're sipping that mia espresso or practicing radical optimism, there's been a lot of fun. Of new music to celebrate. And as the temperatures rise and the charts begin to shift, new contenders for the next summer hit begin to crop up. These next few weeks on Switched On Pop, we're going to be looking at the making of these summer hits, specifically Billie Eilish's new record and Charlie Puth's new single. Should he be a bigger artist? We think so. Find out live with him in the studio. Join me, Charlie Harding, co-host of Switched on Pop, for a Making of a Summer Hit series sponsored by Method. You can find Switched on Pop anywhere. You get podcasts. Here's the truth about AI.
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Transcript generated on 2024-05-30.