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The Keckley Report

Solving Healthcare Workforce Shortages requires Taking Self-Care more Seriously

By August 8, 2022March 1st, 2023No Comments

The Labor Department reported Friday that the U.S. added 528,000 jobs in July including 69,600 in healthcare. The unemployment rate fell to 3.5%, June job openings were down to 10.7 million from 11.3 million in May and government officials announced that the economy has now recouped the 22 million jobs lost in the pandemic.

But the more sobering news is that inflation has negated the workforce’ 5.1% wage gain in the last year and 1 in 5 workers is looking for employment elsewhere for higher pay and better benefits. And it’s even worse in the healthcare delivery workforce—the hospitals, long-term care facilities, clinics and ancillary service providers where 12 million work. During the COVID-19 pandemic, hospital employee turnover increased to 19.5%–five times higher than the general workforce. And today, 45% of physicians report burnout—double the rate pre-pandemic. It has added costs and disrupted care. Daily staffing plan changes, capacity shuffling and wage pressures are now the norm in every healthcare provider setting today.

Appropriately, attention has turned to workforce shortages: near-term solutions including job sharing, restricted hours, use of lower-skilled personnel, cross training and wage adjustments have run their course. But these shortages are exacerbated by supply chain bottlenecks, reimbursement cuts and growing sensitivity to the widening gaps between executive and physician compensation and frontline nurses, aides and support staff. It is likely to get worse: per the U.S. Bureau of Labor Statistics, the healthcare delivery system will need 2.6 million more workers in the next 8 years to accommodate demand even as shortages persist today.

Organizations like the Graduate Medical Education National Advisory Committee (GMENAC), trade groups like the Association of Academic Medical Centers (AAMC) and American Nursing Association (ANA), government agencies like the Health Resources and Services Administration (HRSA) and virtually every national consultancy are sounding the alarm. But ironically, there’s no consensus on exactly how shortages should be measured: that’s the original sin. Lag indictors based on population growth and disease prevalence, the supply and demand of licensed health professionals based on training and accreditation stipulations, and compensation history have been the framework for assessing shortage acuity. It’s shortsighted. Like every industry, lag indicators are decreasingly predictive of the future.

As my former colleagues at Vanderbilt wrote last week in a JAMA Health Forum Viewpoint, “Three deficits in modeling must be addressed to better project—and achieve—the goal of a workforce prepared to meet the health needs of society: improving the health care workforce data infrastructure; using modeling to help set a diversity, equity, and inclusion agenda for the health care workforce; and incorporating innovation and changes in health care delivery.”

They’re right. New technologies, new compensation models, new care management processes, new incentives are being tried. But there’s a fourth that needs equal attention: self-care.

Other industries, like travel, banking, entertainment, publishing, retail et al have built successful business models on the premise that their consumers—armed with needed information—engage directly in decisions and actions consonant with their self-interests. In so doing, fewer workers are required, replaced by technologies and online tools that are customized to the individual needs and preferences of their customers.

In healthcare delivery circles, self-care is dismissed because diseases and treatments are deemed too complicated thus “consult your doctor” or “visit the ED” are the default. That’s the problem: the health system is staffed to the presumption that most consumers are incapable of acting rationally about their healthcare and its associated costs. Jealously guarding the trustworthiness of its physicians, nurses and pharmacists, the status quo leans into paternalism toward patients and staffs accordingly. It’s understandable: the economics of the health delivery system are built on B2B (business to business) trading relationships; consumers are an afterthought in most settings.

It is activation of self-care that disruptors like Amazon, CVS and Alphabet are betting on to right size the healthcare workforce. They recognize that reduced health spending must address two systemic flaws: high unit costs for prescription drugs, medical visits, hospitalization and workforce productivity. Studies by the Bureau of Labor Statistics’ Office of Technology and Productivity have consistently shown much of what the workforce does can be done by individuals for themselves and optimized using technology-enabled CRM (customer relationship management) methods to deliver real-time directives on demand. This applies to as many as 40% of visits to primary care providers for whom an office visit is unnecessary, diagnostic screening tests that can be administered and interpreted dependably, and much more.

Self-care has been defined as “any necessary human regulatory function which is under individual control, deliberate and self-initiated.” In health delivery, it involves actions taken by individuals to maintain their health and wellbeing and/or treat a condition without direct intervention or unnecessary intervention with providers. It’s fundamental to how Gen X, Gen Y and Millennial consumers critique the health system and increasingly the basis for how they choose their providers.

As social determinants of health gain recognition as risk factors, as chronic disease overwhelms the public’s health, as social media gain influence in consumer lifestyle and spending decisions and as the healthcare workforce is stretched, why is the potential for self-care not taken more seriously?

Self-care deserves attention as a critical dimension in re-engineering and right-sizing the healthcare workforce.


P.S. At 3:17 pm EDT yesterday, the U.S. Senate passed the Inflation Reduction Act by a vote of 51-50 with the Vice President casting the tie-breaking vote. The $740 bill was passed under reconciliation allowing a simple majority approval. Key healthcare provisions include…

·        Allows Medicare to negotiate prices for certain drugs directly with manufacturers

·        Requires drug manufacturers to pay a rebate to the federal government if their prices exceed the inflation rate

·        Caps Medicare enrollee out of pocket spending for prescription drugs at $2000/year

·        Extends for 3 years subsidies for purchasing health insurance for low-income populations per the American Rescue Act.

·        But the inclusion of a $35/month insulin price cap failed to pass in the final version.


Melinda B. Buntin, PhD1,2; Jennifer Connell, BS3; Peter Buerhaus, PhD4 Projecting the Health Care Workforce Needed in the USJAMA Health Forum August 5, 2022;3(8):e222430. doi:10.1001/jamahealthforum.2022.2430

US Bureau of Labor Statistics Occupational Health Handbook April 18, 2022 www.

Office of Productivity and Technology, US Bureau of Labor Statistics Office of Productivity and Technology, US Bureau of Labor Statistics

Alexander Segall; Jay Goldstein (1998). “Exploring the Correlates of Self Provided Health Care Behaviour”. In Coburn, David; D’Arcy, Alex; Torrance, George Murray (eds.). Health and Canadian Society: Sociological Perspectives. University of Toronto Press. pp. 279–280. ISBN 978-0-8020-8052-3.

Healthcare Spending

Study: wide variation in state healthcare spending: Researchers analyzed health spending by state and payer. Highlights:

·        In 2019 state-specific per person spending ranged from $7,250 to $14,500. After adjustment for inflation, annualized per person spending growth for each state ranged from 1.0% in Washington, D.C., to 4.2% in South Dakota between 2013 and 2019.

·        The factors that explained the most variation across states were incomes (25.3%) and consumer prices (21.7%).

·        Medicaid expansion was associated with increases in total spending per person, although the median of spending in expansion states showed slower growth in out-of-pocket spending than the median in non-expansion states.

Varied Health Spending Growth Across US Johnson et al States Was Associated With Incomes, Price Levels, And Medicaid Expansion, 2000–19 August 2022


Pew: Majority of U.S. Workers Changing Jobs Are Seeing Real Wage Gains: Per Pew’s American Trends Panel survey of 6174 adults conducted June 27-July 4:

·        Roughly one-in-five workers say they are very or somewhat likely to look for a new job in the next six months, but only about a third of these workers think it would be easy to find one

·        From April 2021 to March 2022, the majority of workers switching jobs (60%) saw an increase in their real earnings over the same month the previous year. Among workers who remained with the same employer, fewer than half (47%) experienced an increase in real earnings.

·        Overall, 2.5% of workers – about 4 million – switched jobs on average each month from January to March 2022. This share translates into an annual turnover of 30% of workers – nearly 50 million – if it is assumed that no workers change jobs more than once a year. It is higher than in 2021, when 2.3% of workers switched employers each month, on average. About a third (34%) of workers who left a job from January to March 2022 – either voluntarily or involuntarily – were with a new employer the following month.

·        From 2019 to 2021, about 48% of workers who changed employers also found themselves in a new industry, on average each month – a pattern undisturbed by the pandemic. The rates of departure from Hospitals and Other Health Services and Public Administration (about 3% or less) were also relatively low, and exits from Repair and Maintenance Services, Personal and Laundry Services/Private Household Services, and Arts and Entertainment (about 5% or higher) were relatively elevated. This general pattern was also present in 2019 and 2020.

Majority of U.S. Workers Changing Jobs Are Seeing Real Wage Gains Pew Research July 28, 2022

Gallup: abortion concerns increase but lag economic issues for voters: Abortion ranks behind three other issues on the “most important” list in Gallup’s July 5-26 update. Inflation (17%) and dysfunctional government or bad leadership (17%) top the list, with another 12% of Americans making general complaints about the economy. In addition to specific mentions of inflation, 5% of respondents mention fuel and gas prices.

Abortion Moves Up on “Most Important Problem” List Gallup August 1,

Morning Consult: inflation top of mind: Per Morning Consult’s poll of 2210 US adults conducted July 22-24: Nearly 9 in 10 U.S. adults report having seen, read or heard something about inflation, with 60% saying they’ve heard “a lot” about the topic. This is in line with similar shares who said they’re “very concerned” about inflation and its impact on their household finances (64% and 61%, respectively).

How Inflation Concerns Are Impacting Consumer Spending Morning Consult August 4, 2022 www.

KFF July 2022: Inflation Tops Voters’ concern: Highlights of the poll conducted July 7-17:

  • Abortion is now a major issue to mid-term voters, especially women between the ages of 18 and 49 where there was a14% increase in the share who say abortion will be “very important” to their 2022 midterm vote (59% in February to 73% in July). Note: 65% of adults disapprove of the Supreme Court decision on Dobbs v. Jackson Women’s Health Center that overturned Roe and allows individual states to decide the legality of abortion access within each state.

  • While abortion is a motivating issue for some groups of voters, the issue still trails inflation and gas prices (74%) as the top voting issue overall. Abortion ranks alongside other top tier issues include gun control (57%) and health care and prescription drug costs (55%). In the past two years, the share who are worried about being able to afford gas or other transportation costs has nearly doubled, growing from 40% in February 2020 to 76% in July 2022.

·        64% are worried about unexpected medical bills, 61% are worried about affording food, 48% are worried about paying their health insurance deductibles, 46% are worried about paying for their prescription drugs (46%), and 40% worry about paying their health insurance premiums.

KFF Health Tracking Poll July 2022 August 2, 2022/

McKinsey: only 19% of households nearing retirement financially prepared: Per McKinsey, 81% of baby boomers may be unprepared for retirement. Highlights:

·        47% of households nearing retirement report that they have not achieved financial sufficiency, (20% who are in the safety net, reliant heavily on Social Security for retirement income and 27% who are financially at risk of not maintaining their working years’ standard of living.

·        34% of households are financially near the line, in that their assets leave little to no margin for shocks like market downturns, continued inflation, or family health changes.

·        19% of pre-retirees likely to be fully financially secure.

US ‘pre-retiree’ households are unprepared to retire McKinsey

Morgan Health: widespread racial disparity in commercially insured population health status: Morgan Health commissioned NORC at the University of Chicago (NORC) to assess health outcomes and disparities among adults with employer-sponsored insurance (ESI). Highlights:

·        60.4% of Black enrollees had high blood pressure, as compared to 40.7% of Asian enrollees, 44.2% of Hispanic enrollees and 46.0% of white enrollees.

·        Black (13.4%), Hispanic (13.3%) and Asian (14.1%) enrollees were more likely to have diabetes than white enrollees [(8.8%).

·        White enrollees were more likely to report heavy alcohol use (31.7%) and illicit drug use (20.6%) compared to Black, Asian and Hispanic enrollees.

·        Even with employer coverage and job-based income, food insecurity is prevalent within the employer-sponsored coverage population. – 7.7% of enrollees were food insecure

Health Disparities in Employer-Sponsored Insurance July 2022

UnitedHealth: patients want more online interaction with their physicians: United Health: Healthcare Access Survey, 4 Findings

 •  74% of patients schedule their appointments over the phone or in person.
 •  36% would prefer to schedule online with either their provider or health plan.
 •  45% of consumers ages 25 to 34 prefer online scheduling but only 28% do so today.
 •  52% of consumers missed a scheduled health care appointment in the past year.

United Health Group, “Consumers Want Better Digital Tools for Finding Health Care: Survey,”
July 20, 2022

States, Abortion

Indiana passes abortion restriction legislation: Indiana lawmakers passed and Governor Eric Holcomb signed a near-total ban on abortion Friday becoming the first state to approve new limits on the procedure since Roe v. Wade was struck down June 24. The Indiana bill bans abortion from conception except in some cases of rape, incest, fatal fetal abnormality or when the pregnant woman faces risk of death or certain severe health risks.

The law’s passage came just three days after voters in Kansas, another conservative Midwestern state, overwhelmingly rejected an amendment that would have stripped abortion rights protections from their State Constitution. Lawmakers in South Carolina and West Virginia have weighed but taken no final action on proposed bans. Officials in Iowa, Florida, Nebraska and other conservative states have so far not taken legislative action.

Indiana Governor Signs First Post-Roe Abortion Ban, With Limited Exceptions New York Times August 6, 2022

Kansas abortion amendment vote drove high turnout: Per Ballotpedia, “Based on unofficial results, 908,745 people voted on the Kansas constitutional amendment compared to 727,360 in the gubernatorial primaries and 718,545 in the U.S. Senate primaries. Turnout on the amendment exceeded overall turnout at the 2018 (457,598) and 2020 (636,032) state primaries. On Aug. 2, Kansans rejected an amendment to provide that the state constitution does not secure a right to abortion. The vote was 58.78% ‘No’ to 41.22% ‘Yes’.”

Kansas is the first state to vote on an amendment addressing constitutional interpretation and abortion since the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision; the referendum was in response to a 2019 Kansas State Supreme Court ruling that the state’s Bill of Rights provides a state constitutional right to abortion.

Ballotpedia August 4, 2022


CMS final inpatient rule requires transparent safety performance reports but limits hospital penalties, overall increase highest since 1998: The 2 most notable changes in the 2087-page final rule or hospitals:

·        Payments to hospitals that meet quality-reporting requirements and are “meaningful users” of electronic health records will increase by 4.3%–up from the earlier proposed 3.2% increase, driven by a market basket update of 4.1% and statutory adjustments resulting in a 0.2% gain. Biggest increase since 1998.

·        Inpatient safety reporting for FY2023 will be mandatory against hospital objections but CMS agreed not to impose Medicare reimbursement penalties for the lowest performing 25% due to operational challenges facing hospitals during the pandemic. The composite score, called the PSI 90, includes the rates of 10 preventable and potentially lethal in-hospital harms such as pressure ulcers, falls resulting in a hip fracture, postoperative respiratory failure, and postoperative sepsis. The rule takes effect October 1, 2022.

Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2023 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Costs Incurred for Qualified and Non-qualified Deferred Compensation Plans; and Changes to Hospital and Critical Access Hospital Conditions of Participation CMS Federal Register 08/10/2022 and

Study: Medicaid expanding use of home and community-based services: Researchers analyzed the use of home and community-based services, particularly through Section 1915(c) waivers and Section 1115 demonstration waivers in state Medicaid programs. Key finding: Nearly every service category saw an increase in coverage and spending, especially support for self-direction and community transition

Skira et al Trends In Medicaid Home And Community-Based Services Waivers For Older Adults Health Affairs August 2022


Private capital gains 37.6% last year: Overall IRRs for Global Investors: 1Q22, 1 YR, 5 YR, 10 YR

·        Private equity 1.6% 46.6% 27.4% 22.5% 17.6%

·        Venture capital -2.2% 50.5% 33.7% 25.3% 17.8%

·        Real estate 7.6% 24.8% 11.8% 11.2% 12.4%

·        Real assets 4.1% 20.7% 6.4% 7.4% 6.6%

·        Private debt 0.6% 14.9% 8.7% 8.3% 9.5%

·        Funds of funds 1.4% 43.0% 24.8% 20.0% 14.6%

·        Secondaries 5.5% 41.6% 18.7% 17.5% 14.3%

·        Private capital 2.5% 37.6% 20.9% 17.8% 14.9%

Private investors had $3.235 trillion dry powder at end of 2021; $1.3 trillion is PE “Institutional investors will typically pause to assess the situation, hold steady in their long-term thinking, and think about tactical ideas only around the margins. GPs should be patient with LPs, settling in for a longer fundraising cycle and taking good care of their existing portfolios.”

GLOBAL Fund Performance Report Pitchbook

Insights into LPs’ Approach to 2022’s Market Challenges Pitchbook June 10, 2022

Pitchbook: plant-based food gaining ground slowly: Since 2011, at least 489 startups have raised $14.2 billion in venture capital (VC) to produce alt-protein consumer products. Pricing is an issue: products are 20-50% higher than traditional counterparts. Plant-based meat and seafood sales in the US grew 74% between 2018 and 2021, a CAGR of 20%.

Pitchbook August 5, 2022

CVS targets primary care acquisition: On the heels of Amazon plans to buy primary-care company One Medical for $3.9 billion. CEO Karen Lynch told analysts last week that there are multiple routes it could take to expand its primary care, “by the end of this year.” Shawn Guertin, CVS’ CFO, suggested during the call that the company would make multiple acquisitions to advance its strategy: “CVS is looking for companies with a strong management team and technology, and a pathway to turning a profit.”

Possible targets include Cano Health, CareMax, One Medical, Agilon, InnovaCare, P3 and others.

CVS Health is gearing up to buy a primary care company by the end of the year. Here are 7 companies the $132 billion retail giant might acquire Business Insider August 4,

Clinical innovation, Care Management

Study: treatment for dementia in rural settings: Researchers analyzed rural vs urban differences in use of diagnostic and management services at the time of early-onset Alzheimer disease and related dementias (ADRDs). Findings: 

“This study found that new patients with early-onset ADRDs in rural areas were less likely to receive neuropsychological testing or visit psychologists but more likely to be diagnosed and treated exclusively by PCPs compared with those in urban areas. These findings suggest that efforts, such as clinician education or tele consultative guidance to PCPs, may be needed to enhance access to specialist services in rural areas.”

Xu et al Rural-Urban Disparities in Diagnosis of Early-Onset Dementia JAMA Netw Open. 2022;5(8):e2225805. doi:10.1001/jamanetworkopen.2022.25805

Study: association between diabetes with an increased risk of cancer clear: Researchers investigated the associations between plasma prostasin and diabetes, and to explore whether prostasin has an effect on cancer mortality risk in individuals with hyperglycemia. Results:

“Prostasin was significantly associated with the incidence of diabetes. The adjusted HR for diabetes in the 4th vs 1st quartile of prostasin concentrations was 1.76. Prostasin was also associated with cancer mortality. There was a significant interaction between prostasin and fasting blood glucose for cancer mortality risk with a stronger association observed in individuals with impaired fasting blood glucose levels at baseline. Plasma prostasin levels are positively associated with diabetes risk and with cancer mortality risk, especially in individuals with high blood glucose levels, which may shed new light on the relationship between diabetes and cancer.”

Bao, X., Xu, B., Muhammad, I.F. et al. Plasma prostasin: a novel risk marker for incidence of diabetes and cancer mortality. Diabetologia (2022).

HHS declares monkeypox public health emergency: Last Thursday, Health and Human Services Secretary Xavier Becerra has declared a public health emergency in response to the growing monkeypox outbreak in the U.S. The U.S. now confirmed more than 7,000 cases, the largest outbreak anywhere in the world. The emergency declaration could help streamline the U.S. response, which has come under criticism for moving too slowly, and raise public awareness about the risks posed by the virus. To date, the federal government has mobilized 1.1 million doses of the monkeypox vaccine though demand is still outstripping supply. The vaccination campaign right now is focused on 1.7 million gay and bisexual men who face the greatest risk from monkeypox because they are either HIV positive or taking medicine to reduce their chances of contracting HIV.