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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join editors from Health Affairs, the leading journal of health policy research, and special guests as they discuss this week’s most pressing health policy news. All in 15 minutes or less.
Hello and welcome back to health fairs this week. I am your host, Jeff Byers. We are recording on Monday, 02/24/2025. Just to let you all know, on March 12, we're gonna be doing a live taping for our other podcast, A Health Podyssey. Rob Lott will be chatting with Yasha Sweeney Singh on her upcoming paper in the March issue of Health Affairs, which is about private equity's effect on the health care workforce.
Jeff Byers:Today, to discuss the latest installment of the vital directions paper package, I'm joined by Victor Zhao from the National Academy of Medicine. Victor, welcome back.
Victor Dzau:Oh, thank you very much. I look forward to talking to you.
Jeff Byers:So Vital Directions began in 2016. In 2021, you partnered with Health Affairs for a set of papers, as well as the current 2025 set of papers. Looking back at 2016 and 2021, what would you say is the most pressing health policy concern, and how has that concern evolved since 2016, and where do you expect it to land in 2029?
Victor Dzau:Yeah. So first is what's the vital directions? It's a series of paper that we commissioned at every turn of administration. So as you said, in 2016, '16, that's, during Trump, and 2020, Biden. You know?
Victor Dzau:So, really, they were published in 2016 and 2021. And at the time, we, of course, we look at to the administration. These are the priorities that we feel the nation face in health and health care, and we assemble groups of experts to write these together around topics and provide, in fact, administration and also congress with kind of a framing and road map of what needs to be done for the next cycle of administration. So that's all really very exciting. That's been very effective.
Victor Dzau:In fact, we've been able to speak to leadership and congress administration about these issues. So if you look at them and the issues facing the nation at that time, they were, you know, the ones such as cost fragmentation, the issue of noncommunicable diseases and communicable diseases, as well as many others. But I think what's really happened since 2021 is a series of things that are almost like a substantial threat. First of all, we didn't have COVID nineteen, and finally, the world woke woke up to a whole issue of pandemics. And now more recently with flu and then pox, we know it's here to stay.
Victor Dzau:And so that in fact is a major change from the first two, series. Second of course is climate change. Also in this period, there's a recognition of impact on climate change and awareness of health, less so before that. Third is a lot of issues of health equity, particularly with Black Lives Matter, many others. So I think that there's a lot of changes in the last, shall we say, four years that has led to really a renewed look at what the emphasis are.
Victor Dzau:You know, along, of course, as you know, with COVID nineteen exposed the problem of public health, misinformation, trust in public health, and in science. And, of course, also, we've seen during the last few years a series of legislative and judicial actions that's shaping health activities, right, about health care, reproductive health, you name it. So I think this is a really particularly important time for this series of vital direction to come out to say, what do we need to look at immediately? And I think, and I will say that there, in fact, there are we're organized around, five areas. Right?
Victor Dzau:One is US health care system has to be transformed better, less fragmented, low cost, and improve outcomes. Secondly, we need to modernize public health. And given all the concerns of public health, how do you make public health more effective? And how do you make public health connected with social care, health care delivery, you name it? Third is, of course, the whole research enterprise.
Victor Dzau:What does The US biomedical research enterprise look like? Fourth is artificial intelligence, a huge area that's coming in that we're looking at now and the future. Then, of course, we all start about women's health and, of course, climate change. So those are the major pieces of this time, this vital directions, very timely, and many common themes emerge in our work for actionable strategies for progress, for new administration and congress. We need more leadership, more strategy, reduce fragmentation, looking at misaligned economic incentive, investment in workforce, and, of course, prioritizing equity.
Victor Dzau:So that's the whole idea of this whole series. I think you're looking at a blueprint, if you will, to inform the priorities of this administration.
Jeff Byers:Yeah. So, you know, the articles were written before the inauguration of Donald Trump's second term, and, you know, we're still very, very early on in that second administration, but the administration is already creating a lot of news. So when you look back at the 2025 priorities and reflect on the, federal actions that have currently taken place in the health care space, So, like, I I ask you, like, one, what's been your reaction? And two, has any recommendations changed from the, you know, writing to the publication?
Victor Dzau:Jeff, you're right. We started this before the election, but we always have to do that in anticipation of election. Otherwise, we won't have the things ready. Right? We just published in January.
Victor Dzau:But I think the areas we identified is really remain true irrespective of what administration did this. Who would disagree that we need much better health care system that's not fragmented, that's affordable, and that is in fact transformed? Who would disagree that public health needs to be doing better? Who would disagree with the fact that we need a much better research strategy? And, of course, think about AI and climate change.
Victor Dzau:These are things that's happening and going in the future. So I don't think it changes anything, except when Trump comes in, as you know, the last thirty days, this executive order and the push she had in certain direction, I think, took most people by surprise, and most people are reacting to it. I would argue that our errors remain true because these are the priorities. These are the long term immediate long term issues. What What Trump has come in to say would be, oh, I wanna look at Medicaid.
Victor Dzau:I'll look at this. I'll look at DEI. No. We need to figure out how to respond to them, but I don't think anything's changed because what we need is affordable, accessible, equitable care what improve health outcomes, will reduce health care spending, and we really want to have much better integration of public health, social care so that people can get to it, and all the things we had talked about earlier. So I think it doesn't change much except we need to look at specific actions and how to be sure that not only we advise his administration, but we also protect the country from things which are under intended consequences.
Jeff Byers:Yeah. And so kinda looking back at those recommendations that you brought up earlier, and that's in the package of the paper. And I really encourage listeners to check out all the papers in the package. We published them as an ahead of print in January of twenty twenty five, and they are currently published in the February 2025 issue of Health Affairs. You can find them all there, so check that out.
Jeff Byers:And in those papers, you touched on investing in the health care workforce, which we know is a big issue around the country. So it was written that building an AI competent health care workforce, is mentioned as is building a, ready workforce in public health. So in the biomedical section, you write career pathways are unclear, and a lack of workforce diversity stifles both innovation and equitable health outcomes. So I, you know, am, like, looking at this and wondering if I'm a hospital operator or business owner or an administrator or a policy officials, how might I actually, be looking into a vest into the new generation of health care workers? I know I'm gonna throw a bunch of questions, but, like Yeah.
Jeff Byers:What struggles might they have, you know, that their previous generation did not? What advantages? So what can you tell us about that section?
Victor Dzau:Well, I mean, after all, you know, the only way to go forward do thing is through people and through the workforce, and that's why it's so important to invest in the workforce. If you look at where we are today, let's say, in health care, even in public health, we're having a tremendous shortage, of workforce, and we also have unequal distribution of providers. And that's because, first of all, we have an aging workforce population. Second, there's burnout and, tremendous problem with retention. Third is the demand for care is increasing.
Victor Dzau:So we need effective workforce. This is a question. We know, for example, if you look at the data, primary health care professional shortage areas, which are designated, that affects about 75,000,000 people, 20% of the population. There's at least about 7,000 areas which are short in primary care and workforce. We also know that the burnout issue is high.
Victor Dzau:During COVID nineteen, it actually goes up to as high as seventy, eighty percent of doctors and nurses. It might have settled a little bit, but the retention, people are saying, I'm not coming back. Or when I I'm gonna early retire. Right? And then by 2030, a third of physician will be over 65, and 500,000 nurses expect to retire by 2025.
Victor Dzau:So we have tremendous shortage. Demand is rising because by 2030, '1 in '5 Americans will be 65 and older. That's the issue. So we need to invest not only in current workforce, but the future generation workforce. In the research arena, same problem because fewer and fewer Americans are going to research.
Victor Dzau:The STEM education, as you know, needs to be greatly improved. Science is no longer seen as a desirable, you know, area of profession. And then we're also a highly dependent both health care and research and international students. If particularly, if you look at in areas of physics and others, I mean, most of the majority of leaders are from international training. I myself am immigrant coming from a different background, and we need that.
Victor Dzau:And, of course, as you know, these days, immigration policy, etcetera, makes it really difficult. We also need to pay our workforce better and to retain them. So there are many issues. I believe the highlight is let's start planning how to create, retain, and enable the generation of health care workforce researchers to make sure we can carry out the work for the nation. So we also need to train the workforce for the future.
Victor Dzau:And in health care, digital technology, AI is really, really important. So we need to train them, include, in fact, requirement for training so that they can use manage information, digital innovation for care delivery. Right? I think that's really so important. And we also need to be sure that workforce begin to work across, as you talk about fragmentation, the different sectors in public health, health care, social sectors, etcetera.
Victor Dzau:So that's another important area of workforce, readiness for the future.
Jeff Byers:Maybe we can touch on this, maybe not, but I am curious about, like, when you mentioned AI and paying the workforce better, which I think is desperately needed, Like, how might those hospital operators or practice managers think about those investments into their workforce, especially when they think about what their you know, since they they are businesses?
Victor Dzau:Yeah. You know, my feeling is investing in those areas is only gonna there's a good business case because, first of all, you'll be more efficient. Secondly, in the workforce shortage that in fact the use of digital technology, AI, may allow you to actually work with, fewer people, increasing efficiency. AI, if done right, can help you look at good clinical decisions. So I think there's a lot of reason to invest in it because long run and I know health systems are investing in it.
Victor Dzau:No question. Not only workforce, but using AI to manage workflow, possible beds. Right? Predict who's likely to get sepsis, who's likely to end up, you know, crashing or not, and therefore being able to manage the patient much better. That's certainly an efficiency issue as well as, of course, better health care altogether.
Jeff Byers:So another theme, in the papers was reducing fragmentations. So fragmentation and working in silos has been a topic of concern for as long as I can remember. Have we made any concrete movement on this? Is there any optimism to share on this front?
Victor Dzau:Yeah. Well, not enough to be sure. Right? When you're think about fragmentation, we have fragmentation within the health care itself, fragmentation across the health care stakeholders and related areas, and with fragmentation with regards to strategy, policy, and funding. So all those three areas.
Victor Dzau:Let begin with the first one. When you think about health care, we think about primary care, specialty care, long term care, rehab, community care. And as you know, these are highly fragmented, and, more and more systems are looking at how to actually make them much better seamless in a continuum of care. Right? A patient frequently have to go from one to the other, separate appointments, getting different messages.
Victor Dzau:So one, of course, major area is using electronic health record. But as you all know, we have trouble with interoperability and making sure that we have the same platform, particularly records from community health, social services, and others. So I think this is a big fragmentation. Such an issue needs to be integrated seamless for patient care and, hopefully, also with financial incentive and measurements of outcome that can enable us to do a much better integration. That's one point.
Victor Dzau:Second, beyond health care, we have fragmentation with public health, with social care, with payers, and others, community organization. Right? We learn, for example, from COVID nineteen, the issue of social determinants that if we can integrate all of these things, then you provide your patient much better social care and, therefore, maybe less need for medical care. So these things need to be happening. And, certainly, I would say during the, as you see a paper from Mark McClellan about reforming public health needing much better coordination across sectors using samples by state and local governance collaborating to look at how to enable, a much better integration or coordination across different sectors.
Victor Dzau:And third is policy and funding. And that's another problem. Right? As I mentioned, state, federal government, even counties are all making different decisions, and, also, they all have somewhat different financing needs and pressures, and they need to come together to be a lot more integrated thinking about those things. And research and our research paper by Luis talk about the difficulty in looking at fragmentation of funding between philanthropy, foundations, NIH, NSF, and rarely do we look at how to integrate and align this funding in order to get the right outcome, particularly in research areas.
Victor Dzau:So there's a lot of work need to be done. Are we making any progress? Well, certainly, I think there's a lot more recognition now and willingness to do this. So, for example, we have seen that in the places like North Carolina where I live, that in fact, there are efforts to look at how to use Medicaid dollars, look at social determinants, pay for housing and others in order to integrate the social and the medical care aspect of things. So I think that the McClellan paper and the Don Berwick paper really address many of these issues.
Jeff Byers:My colleague, Rob Lott, spoke with Don Berwick about his paper in the vital direction series, on the health policy podcast. So I don't wanna retread what they discussed too much, but I will ask as we wrap up, especially in looking at the recommendations for public health, is there any small actionable items that can help push health care into more of a team sport?
Victor Dzau:Yeah. Thank you for using those words because Mark McClellan's paper and his colleague says, we need a team spot approach. What does that mean? You know, at the end of the day, population health is everybody's responsibility. Right?
Victor Dzau:So those who run hospitals are thinking about how do I take care of patients that come into my door, but they also need to think about what happens after they leave my door, and how do I keep them healthy, you know, within where they live, etcetera. And we all know about social terms of health. Public health, we will think about how do we keep the public healthy and particularly community health. And there are, of course, more and more organizations working on community health, community health workers, and others. So I think the whole idea in social care I mentioned is a is a team spot.
Victor Dzau:How do you actually collaborate, align, and share accountability across different programs at the end to improve population health? That's the key issue. And to do that, as you said, you have to start changing incentives and integrate the data, which is so important, and create partnership. So there are indeed efforts now to bring together health care delivery, public health, social care together to create ways to align, to create teamwork, and also to share data. So to get beyond the silo to be able to look at things together and measure things together.
Victor Dzau:So there's enough several initiative that's going right now that is in fact discussing this. I do think that federal legislation and administrative action can be helpful because they can incentivize, you know, the, coming together, if you will. They can enable more data sharing, etcetera. And, of course, all that along working along, as I said earlier about, was a state like in Indiana, where in fact they have a multisectoral statewide commission to form to bring together everybody, including business, to look at how to promote health care priorities. And the federal level, you can look at a federal plan for equitable long term recovery resilience and to look at changes need in federal government.
Victor Dzau:So during the last administration, certainly, there was effort to bring together all relevant federal government departments and agencies to look at how do we look at working together, how to foster community center collaboration and investment to strengthen these systems, and, ultimately, a whole government approach on resource on communities. So lots of things going on. I think if you read those papers, it's all in there.
Jeff Byers:Victor Zhao, thanks again for joining the program. Before we head out, is there anything you wanna highlight regarding vital directions that we haven't touched on?
Victor Dzau:Jeff, one thing I want your audience to know is that we're actually releasing this the the series as a webinar on Thursday, the twenty seventh. And, of course, you are publishing this on Friday. So when people hear this podcast, they can go to the NAM website and log in to listen to the webinar. We'll have Mark McClellan, Don Berwick, Sandra Bill Frist, Al Reese, Paula Johnson, and Michael Finney all reviewing what their findings of each one of those chapters. So please log in our website and, hear it, when you hear this podcast.
Jeff Byers:Again, Victor's out. Thank you for taking the time, and speaking with us today on Health Affairs This Week. To you, the listener, if you enjoyed this episode, Please send it to the futurist in your life, and make sure you leave a review, give a comment on Spotify, give a rating, all that good stuff. It really, really helps people find the show, and we want to continue making it for you. So please share it far and wide.
Jeff Byers:And with that, I hope you have a great rest of the week, and we'll see you next time on Health First This Week.