The health care workforce reform.

• Author: Lamm, Richard D.

Public policy, like von Clausewitz's generals, tends to fight the last war. Too often we legislate for the world that was--not is. "Policy is formed by preconceptions and by long implanted biases," Barbara Tuchman says. "When information is relayed to policymakers, they respond in terms of what is already inside their heads and consequently make policy less to fit the facts than to fit the baggage that has accumulated since childhood."

Public policy is obliged to recognize and adapt to new realities. The old world of public policy is always in tension with the new, and change does not come easily. Let me use the example of reforming our health care system. As we struggle to rationalize the financing and delivery of health care, we too often neglect a critical component--the health care workforce. America's 10.5 million health care workers have a tremendous impact on the cost, quality and accessibility of our system. America trains the wrong numbers and types of providers and does not use them effectively. The old world of care delivery is changing dramatically, and without a similarly dramatic change in the health care workforce, we will create irreparable tensions. A new reality is upon us.

States, which control the education and regulation of health care providers, must craft new and assertive public policy to produce a health workforce that can deliver the promises of a reformed system. Some states are responding, and many have realized that by changing education and training, regulation and utilization, the health care workforce can become the foundation of an efficient, high quality and equitable new system.

As a general rule, state planning has seldom been comprehensive. It usually targets specific provider shortages and avoids the heavy lifting necessary for more comprehensive solutions. Work-force reform requires data collection, analysis and action. Statewide, or even regional, public-private consortia should be formed to ensure that schools train the right types and mix of providers and that the states regulate them efficiently. Washington, Missouri, Colorado, New York and a number of other states have begun to address workforce planning comprehensively.

The shortage of primary care physicians and the expansion of managed care should drive states to scrutinize their $3 billion investment in health professions education. Public money should fund public needs. State medical schools should reduce the number of specialists and...