119 Pere MarquetteLansing, MI 48912(517) 485-4477(517) 485-4488 Faxppa@publicpolicy.com

The Affordable Care Act is here. Now how do we take care of all of these people?

Michigan's Health Care Workforce in the 21st Century

Laurence S. Rosen, Ph.D.Michigan Legislative Briefing

May 7, 2013

Where are we and how did we get here? Demographics

Economics

Changes in health care delivery

Health information technology (HIT)

Affordable Care Act of 20102

Demographics

2000 2010 2020 20300%

10%

20%

30%

40%

12.7% 12.8%

16.0%

19.5%

20.9%21.2%

27.4%

35.2%

65+ Dependency ratio

Year

Pe

rce

nta

ge

of P

op

ula

tion

Source: Census Bureau, Interim State Population Projec-tions, 2005.

We’re Getting Older Not Much Migration TO Michigan

-55,000

-45,000

-35,000

-25,000

-15,000

-5,000

5,000

15,000

25,000

3,818

16,225 17,000

-17,963-42,423 -32,982

International Migration 2010 - 2012

Domestic Migration 2010 - 2012

Source: Census Bureau, State Population Estimates, 2010-2012.

3

Economy: Changing Workforce

19901992

19941996

19982000

20022004

20062008

20102012

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Manufacturing Health Care

In T

hous

ands

U.S.

19901992

19941996

19982000

20022004

20062008

20102012

0

50

100

150

200

250

300

350

400

450

Manufacturing Health Care

In T

hous

ands

Michigan

Source: U.S. Department of Labor, Bureau of Labor Statistics, Employment Data Tables; calculations by PPA.

4

Changes in Health Care Delivery Surgical centers

Urgent care centers

Retail health services

Accountable Care Organizations

Hospital consolidation

Walgreens

5

Changes in Health Care Delivery

More ambulatory care

More hospital care Sicker patients Shorter stays

Robotic surgery Telemedicine Electronic

medical/ health records

Ambulatory Visits, U.S. 1995-2008

0

400,000

800,000

1,200,000

1,600,000

1995 2000 2008

Year

Millions Physician offices All sites*

Source: Health, United States, 2010. Table 91.

* Includes physician offices, hospital outpatient departments, and hospital emergency departments.

6

Health Information Technology Electronic health

records Meaningful use Interoperability

Regional health information organizations

Health insurance marketplaces

Telemedicine Practice

management Care management

Experiencing IT staff shortages

Staffing challenges impact meaningful

use

Hiring new talent to support IT

0% 10%20%30%40%50%60%70%80%

67%

59%

75%

Health Care Provider CIO Chal-lenges, 2012

Source: 2012 CHIME CIO Survey; PwC Health Research Institute Human Capital Survey, 2012.

7

Impact of ACA on Patients

Up to 725,000 new patients through the Exchange

Up to 782,000 new adult Medicaid patients with Medicaid expansion

220,000 new adult Medicaid patients even without Medicaid expansion

Approximately 2 million additional office visits per year

8

Exchange-Eligible Population in Michigan Will Exceed 725,000

138% - 149% FPL

150% - 199% FPL

200% - 249% FPL

250% -299% FPL

300% - 399% FPL

Unin-sured

38378 146925 109461 84085 103840

Self-pur-chased Insur-ance

9921 49429 48661 50969 83715

25,000

75,000

125,000

175,000

225,000

Source: Census Bureau, American Community Survey, 2009-2011; calculations by Public Policy Associates, Inc.

9

Potential Adult (18 to 64) Medicaid Expansion in Michigan, 2014

Below 50% FPL 50% to 99% FPL 100% to 137% FPL Total Below 138% FPL

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

260,869 264,334 256,660

781,863

With Coverage Income as % of FPL

Source: U.S. Census Bureau, 2009-2011 American Community Survey, Table B27018, Public Health Insurance.

10

ACA Impact on the Health Care Workforce

Demand is occurring at ALL wage levelsPhysiciansRNs Mid-level professionals

Therapists Technicians

HIT Nurses aids, home health aids,

home care aids11

New Workers Needed by Provider Site, Michigan, 2010- 2020 (Before ACA)

Source: EMSI, 2011.

59,009

24,585

19,612

-

10,000

20,000

30,000

40,000

50,000

60,000

Ambulatory Care Hospitals Long-term &Residential Care

12

MD and DO Supply and Demand in Michigan to 2020

2005 2010 2015 2020 25,000

27,000

29,000

31,000

33,000

35,000

37,000 36,244

30,189

Demand Supply Projected shortages Psychiatry Urology Pathology Surgery Radiology OBGYN Family practice,

general practiceSource: Michigan State Medical Society and Public Policy Associates, Inc., 2005.

13

Nursing Supply & Demand Aging nursing

workforce

Burnout and early retirement

Insufficient nursing faculty

Expanded need for clinical rotations

Applicants exceed nursing school seats

2005 2010 2015 2020100,000

110,000

120,000

130,000

140,000

150,000

120,000

140,000

Michigan RNs, FTE Supply and Demand, 2005 to 2020

Projected Supply Projected Demand

Source: Coalition of Michigan Organizations of Nursing, 2005.

14

New Workers Needed by Occupation in Michigan, 2010 – 2020 (pre ACA)

Physical therapists

Pharmacy technicians

Licensed practical nurses

Medical assistants

Nursing aides

Registered nurses

Home health aides

0

2,00

04,

000

6,00

08,

000

10,0

00

12,0

00

14,0

00

16,0

00

18,0

00

1,900

2,400

3,500

5,300

10,000

16,900

16,900

Number of Workers

Source: Public Policy Associates, Inc., unpublished data, 2011.

15

Hospital Demand Survey

Greatest Expected Growth

RNs Lab technicians Physical therapists Pharmacy

technicians

Hardest to Fill

Physical therapists RNs* Pharmacists Certified Registered

Nurse Anesthetists (CRNAs)

* Newly graduated nurses; ADNs

16

Source: Public Policy Associates, Inc., unpublished data, 2011.

Long-Term Care Demand Survey

Greatest Turnover

Certified nurses aids (CNA)

Licensed practical nurses (LPN)

RNs Food services &

housekeeping staff

Hardest to Fill

RNs LPNs Directors of nursing Long-term care

administrators

Source: Public Policy Associates, Inc., unpublished data, 2011.

17

Demand: Support Occupations, by Region, 2010-2020

1st 2nd 3rd 4th 5th

Southeast MichiganHome health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

South Central MichiganHome health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

Southwest MichiganHome health aide

Nurses AideMedical assist.

Dental assist.

Med. Transcript.

West MichiganHome health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

Genesee-Lapeer-Shiawassee

Home health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

East Central MichiganHome health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

Northern Lower Michigan Nurses AideHome health aide

Medical assist.

Dental assist.

Med. Transcript.

Upper PeninsulaHome health aide

Nurses AideMedical assist.

Dental assist.

P.T. Assistant

Source: EMSI, 2011.18

Supply: Community Colleges in Michigan

Top 10 Health Care Degrees/Certificates Awarded by Michigan Community Colleges, 2010-2011

Registered Nurse 2,581

Licensed Practical Nurse 1,334

Nursing Assistant/Patient Care Assistant 1,149

Medical/Clinical Assistant 409

Emergency Medical Technician 401

Medical Insurance Specialist/ Medical Biller 254

Phlebotomy Technician/Phlebotomist 226

Surgical Technician 185

General Allied Health 183

Medical Administrative Assistant 180

Source: Michigan Community College NETwork, Workforce Development Agency, State of Michigan, 2012.

19

Nursing Supply and DemandSupply Factors

Aging nursing workforce

Burnout and early retirement

Faculty shortages Shortage of clinical

sites in all areas Applicants exceed

nursing school seats

Demand Factors Insured population

growth Expanded Medicaid

population Growing need for

nurses in primary-care and ambulatory-care settings

20

Future Nursing Shortages

Michigan RNs, FTE Supply and Demand, 2005 to 2020

120,000

140,000

100,000

110,000

120,000

130,000

140,000

150,000

2005 2010 2015 2020

Projected Supply Projected Demand

Source: Coalition of Michigan Organizations of Nursing, 2005.

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

75,000

80,000

85,000

90,000

95,000

100,000

105,000

110,000

115,000

Nursing Demand, 2010-2020

Low Series (EMSI) High Series (PPA)

Source: EMSI, 2011; Public Policy Associates, Inc., unpublished data, 2011.

21

Prac

tical

Nur

sing

Ce

rtific

ate

Ass

ocia

te D

egre

e in

Nur

sing

Bach

elor

of

Scie

nce

in

Nur

sing

BS to

RN

Deg

ree

Mas

ter

of S

cien

ce

in N

ursi

ng

Doc

tora

te in

N

ursi

ng

Prelicensure Programs Postlicensure Programs

0%

10%

20%

30%

40%

50%

60%

70%

26%31%

38% 40%

56%

50%

Major Obstacle: Shortage of Nursing Faculty by Education Provided

Source: National League for Nursing, 2012; Annual Survey of Schools of Nursing, 2011.

22

HIT Impacts on the Health Care WorkforceCreates entirely new health care

occupations Practice workflow and information

management redesign Clinician/practitioner consultants Implementation support specialists Implementation managers Technical/software support staff and

trainers

Expands health care workforce

23

HIT Impacts on the Health Care Workforce (continued)Expands staff knowledge and

skills

Requires new education and training resources

Facilitates evidence-based practice

24

HIT Training in Michigan

Demand: 50,000 nationwide 2,000-3,000 in Michigan EHR/EMR in hospitals and physician offices

Supply: HITECH Act and ACA fund training Train up to 2,700 techs annually

Delta College Lansing Community College Macomb Community College Wayne County Community College25

Diversity in Michigan’s Health Care Workforce

White77%

African American14%

Other5%

Hispanic (any race)4%

Michigan Population, 2010 

White, Non-

Hispanic

African America

nAll

Others

Michigan 76.60% 14.00% 9.40%

Dental hygienists 94.00% 1.00% 5.00%

Dentists 90.00% 3.00% 7.00%

LPNs 82.80% 12.20% 5.00%

RNs 87.00% 5.80% 7.20%

Pharmacists 86.00% 3.00% 11.00%

Physician assistants 92.00% 2.00% 6.00%

Physicians 71.90% 4.20% 23.90%

Source: Census of Population, 2010.

Source: MDCH, Bureau of Health Professions, 2010.

26

Health Care Degrees Awarded to Michigan Minorities, 2009-2010

Associate's degree Bachelor's degree Master's degree Professional de-grees and Ph.D.s

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

13.3% 13.6%

20.7%

25.6%

23.0% 23.0% 23.0% 23.0%

Minority Degrees Awarded Minority Population

Source: U.S. Department of Education, IPEDS database, 2011.

27

Diversity in RN Education

Source: American Association of Colleges of Nursing, http://www.aacn.nche.edu/leading-initiatives/research-data/Enrollment-by-State.pdf.

Black Asian Multi-race Hispanic0%

2%

4%

6%

8%

10%

12%

14%

16%

4.2%3.4%

1.0%

2.2%

14.1%

4.4%

2.3%

4.4%

BSN Degrees Awarded by Race and Ethnicity, Michigan, 2011Degrees Awarded Population

28

Conclusions

Demand will grow at all levels Professionals: MDs, DOs, RNs, NPs,

PAs Mid-level: Physical/occupational

therapists; laboratory, imaging, and pharmacy techs

Entry level: Nursing assistants, home health aids, home help aids

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Health Info. Tech.: All levels—from billers and coders to programmers and business analysts

29

Issues We Need to Address

Nursing faculty shortages Home health and home care

workers Low wages High turnover Inconsistent training

Health care workforce diversity HIT growth Growing opportunities for mid-level

health care workers30

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