How our Healthcare Workforce is Adapting to COVID-19: A Q&A with GSPP Alum Erin Fraher

The COVID-19 crisis has demanded a rapid rethinking of how we deliver healthcare. We spoke (virtually, of course) with GSPP alum Erin Fraher (MPP ‘93) about how to flex our nation’s healthcare workforce, her recent perspective in the New England Journal of Medicine, and how the COVID-19 crisis can inform the future of healthcare delivery. We even learned how to frame our messages to public leaders so that they will hear us, and how Fraher’s GSPP training has influenced her career as a scholar-practitioner. Erin Fraher holds a joint appointment as Associate Professor in the Department of Family Medicine and Research Assistant Professor in the Department of Surgery at the University of North Carolina School of Medicine. She is also the Director of the Carolina Health Workforce Research Center. 

You've spoken to the need to cut through bureaucratic barriers and adapt regulations to rapidly expand and sustain the U.S. healthcare workforce throughout the COVID-19 pandemic. What are some of the biggest regulatory barriers to deploying the workforce we need?

The way that we regulate the health professions is a state function, so each state has its own regulatory frameworks. In some states, nurse practitioners (advanced practice nurses) can practice relatively freely, while in other states they are heavily regulated. 

In my own state of North Carolina, nurse practitioners are supervised by physicians. Although there is significant heterogeneity across states, one consistent feature is that regulatory bodies have numerous administrative barriers, such as requirements to submit documentation for licensure, participate in a criminal check, and other hurdles. There are regulations around who can practice where, and in what way. It is intended to protect the public, but it makes it more challenging to quickly flex or surge your workforce. For instance, our nursing board is required to work with the medical board any time they want to change a nurse practitioner’s scope of practice. The medical board must host joint rulemaking procedures, which the rules commission then has to approve. It takes a really long time.

Recently, North Carolina was able to get the licensing process for respiratory therapists who are critical for treating COVID-19 (they run the ventilators) down to 24 hours. So my question is, if you can become licensed in 24 hours during a pandemic, why can't we do this all the time?

What else should we be doing to overcome these barriers?

One thing that is near and dear to my heart is what we call scope of practice barriers. Every licensed health professional has a scope of practice which mandates what that professional can and cannot do. For example, in my own state, we have clinical pharmacist practitioners (CPPs) who are permitted to manage medications for patients, including, for example, diabetic patients’ insulin. It makes sense to allow pharmacists to play a larger role in managing chronic disease, thereby freeing physicians to devote more time and resources to patients with more complicated health needs. However, in North Carolina, CPPs are supervised by a physician. We had CPPs who wanted to provide care to COVID-19 and non-COVID-19 patients, but since some of those patients were not patients of their supervising physician, they were prevented from acting. 

We have requirements that certified nurse midwives must be supervised by a physician. When COVID-19 hit, many pregnant women, unsurprisingly, no longer wanted to give birth in hospitals. But since these certified nurse midwives did not have supervising physicians, they could not accept these patients. A fifth of our workforce in rural areas are nurse practitioners. But if that nurse practitioner cannot find a supervising physician, they cannot practice. These are the kinds of regulatory barriers that make no sense, and that prevent us from deploying the workforce as needed.

These regulatory barriers are often due to turf battles between professions. Liability is also an issue; people are afraid of being sued for practicing in ways that are perceived to be outside their scope of practice. In several states, the governor signed an executive order that said in this state of emergency, you cannot sue people for practicing in good faith in an emergency outside of their scope. This is technical, but really important. And now we are all waiting to see what happens when the state of emergency is over.

Are there potential liability risks at stake in broadening scope of practice, in terms of protecting the public?

I believe there is a much bigger risk in not broadening scope of practice. Consider the fact that nurse practitioners are not supervised in most states, and they do just fine. The fact that North Carolina requires them to be supervised is not based on evidence: if you look at the evidence, it shows that nurse practitioners increase access to care and are more likely to serve vulnerable populations, including those on Medicaid.

Have you been involved in efforts to get the word out on your research and recommendations? How has this been going?

My work related to COVID-19 is a great example of how I’ve learned from my policy training. Being somebody who is known as an expert in health workforce issues, regulation, payment, and training, the state reached out to me early on and asked for advice on what to do to prepare for COVID-19. That is your public policy dream: the Secretary of Health and Human Services asked me what I thought! I quickly assembled data and resources and helped them think things through: We have to prepare our workforce in hospitals first because that's where the acute cases are going to hit; we have to think about people who are going to be on a ventilator, nurses, respiratory therapists, and physicians. But we also need to have a plan for the 80% of our patients we expect will be monitored at home, how to discharge people from the hospital that might still be contagious, and outbreaks in long-term care. My job was not only to synthesize research from all over the country, but to translate academic research into messages that the state could digest. 

I recently gave a presentation for nurses on framing, centered on how to frame your messages in ways that will be heard outside of academia and that tap into an individual’s own understanding of the issues. It is humbling to boil down a huge amount of nuanced research in ways that are digestible. In this case, I used a hockey metaphor: on a hockey team, you have your first, second, and third line of defense. During the COVID-19 crisis, your first line includes respiratory therapists and acute care physicians – but they will get sick themselves, or will have to stay home and take care of their families. Your second line is the people you are going to retrain to step into these positions. Your third line might be a retired workforce, or people you never anticipated. My recent perspective in the New England Journal of Medicine was an example of my efforts to shape the narrative on the workforce, ahead of the curve. My goal was to convey that I understood how they had rightfully focused on surging ICU beds and ventilators – but to move them towards thinking about who was going to staff them, and how to protect their workforce. That paper was the fastest process, but as a policy wonk, when you are trying to get your messages into shaping the narrative, you have to be quick with your messages. That is something that I want to tell Goldman students: it is important for students to know that you have to act quickly to get your data analyzed, synthesized and framed if you want to get in on time to influence policy.

Did the state hear your message?

They heard some of my messages. The Executive Order that our governor signed reduced the regulatory barriers and waived rulemaking, and these were important steps. But they did not hear all of my messages. And that is humbling. That is something that I have learned: despite the fact that people say policymakers are not relying on evidence, they are. But there is also a lot of political power that gets exerted. And I am an academic, trained to be objective. Some of my recommendations did not get adopted because of the professional turf wars that I alluded to earlier. And that is understandable. That is the way it works.

One of the other lessons that I have learned as someone who has been sitting between the academy and policymakers is incrementalism. I have a hard time with incrementalism: I am impatient, I know what you should do. And it has taken me 25 years to understand that I need to keep hammering the message and shaping the narrative. I tell my students not to be dissuaded. If you have a policy issue that interests you and you have evidence, you have to keep coming back every time the policy window opens. You will keep banging your head against the door, but you will get let in. That has been the slowest thing for me to learn.

What can the rest of the country learn from North Carolina's experiences or example?

I wish that I could say we have been super innovative in North Carolina. In fact, our governor did not sign an executive order allowing nurse practitioners to practice without supervision. If I were to look for lessons, I would look to the state of Michigan. Michigan’s governor, Gretchen Whitmer came out early and signed an excellent executive order that allows the healthcare workforce to be flexibly deployed. It allowed nurse practitioners to practice full scope, brought in the retired workforce, and included additional provisions to quickly allow the workforce to both surge and sustain. She did a beautiful job.

Once the pandemic subsides, how should we be evaluating the workforce changes? What can we learn from this crisis to inform the future use or development of our healthcare workforce?

These were complete natural experiments, with a definite pre-post period. There were significant expansions in scope of practice. Suddenly, the Centers for Medicare and Medicaid Services allowed telehealth to be expanded. Previously, only physicians used telehealth; now nurse practitioners and social workers may participate. Formerly, we only used telehealth in certain places; now it can be used at home. Providers are getting paid the same amount to see patients by a video as in person. So are the patients happier, and getting more care because it is more convenient? We have created this incredible level of variation in how we pay for health professionals to care for their patients and how we regulate our workforce. The number of things that we will be able to study about the long-term effects are going to be remarkable. 

Unfortunately, some of these changes are threatening. We need to consider, for instance, whether it is more efficient for providers to reach their patients via video, or if it changes the way they care for their patients. Several of the providers I work with have told me they are suddenly more efficient because if they know a given patient is healthy and can be seen virtually, they are able to focus on seeing their chronic care patients in person. I do not want to understate the tragedy of what is happening, but in terms of the overnight restructuring of how we deliver healthcare services, it has been remarkable. 

In addition to holding a PhD in Health Policy and Management, you are a graduate of GSPP. How has your Goldman MPP influenced your approach or perspective?

To this day, I live by the Eightfold Path [a unique approach to policy analysis developed by GSPP Professor Emeritus Eugene Bardach]. The Eightfold Path will stay with you for the rest of your life. I am reliving this now because my daughter is studying public policy as a Duke undergraduate student. She was recently frustrated after meeting with her advisor, because he kept telling her she had not defined the problem. I remember having this exact conversation with Professor Eugene Bardach, multiple times, and being so frustrated, too. But that ability to define the problem and criteria, weigh the problem against criteria, and project the outcomes – that skillset is remarkable. Most people do not think like that. But for the rest of their lives, when policy problems are presented, Goldman alumni will be able to think things through.

I am a big fan of the 48-hour memo. That is the story of my life. When the pandemic hit, I was the person synthesizing information about the healthcare workforce needs for the state and analyzing national policy as well. The 48-hour memo was my preparation for learning to quickly synthesize and analyze information, and then message it to policymakers who do not have time to blink. It helped me build the confidence that I could turn something useful around that fast. It was not fun, but after doing this a few times, I learned I could do it. 

GSPP also gave me a deep appreciation for stakeholders and stakeholder analysis. I am in a field that is highly contested between physicians, nurses, payers, and insurers. I often joke, I am like an anthropologist of the health professions. I have developed an ability to change my frame, and understand where physicians, nurses, and social workers are all coming from.  

I also carry with me a deep objectivity. I am in North Carolina. We have a Democratic governor and a Republican legislature. I am often called down to Raleigh to give testimony to legislators. My goal is that legislators never identify my own personal politics; if I am called to provide expertise, I am not asked to talk about my politics, I am asked to talk about my research and what it means for policy making. GSPP allowed me to define my identity as a policy analyst and to separate my own politics from the policy problem, which is a gift and skill.

Finally, GSPP gave me a valuable, transferable skillset. At the time, I was interested in workforce development, which was the subject of my Masters paper. I thought I would never want to work in health policy, yet here I am. I tell my students that they may fall in love with a certain branch of policy, but not to be surprised if they switch. The beauty of policy is that you're learning a skillset: quantitative analysis, economics, cost benefit analysis, law, political theory and speaking truth to power. But it does not matter what your focus is because it all draws from the same toolbox. That is the beauty of GSPP: you can switch what you are interested in, because they give you such a strong foundation.