a primer on the health workforce in the united statesa primer on the health workforce in the united...
TRANSCRIPT
A Primer on the Health Workforce in the United States
Erin Fraher, PhD, MPP Assistant Professor
Departments of Family Medicine and Surgery, UNC Chapel Hill Director, Program on Health Workforce Research & Policy
Cecil G. Sheps Center for Health Services Research, UNC Chapel Hill National Health Policy Forum
February 20, 2015 Washington DC
Presentation Overview
• Why do we care?
• Who is in the health workforce?
• Do we have enough? Are they in the right places?
• Education
• Regulation
• Federal versus state roles
• Hot workforce topics
Why do we care?
• ~50% of total health care costs are wages
• 18 million health and social assistance jobs
• 13% of total employment in the United States
• 2% annual growth rate, compared to slightly less than 1% in overall employment
Who is in health workforce? The usual professions you think of…
Physicians and Surgeons 708,170
Nurse Practitioners 154,000
Physician Assistants 95,583
Registered Nurses 2,661,890
Licensed Practical and Licensed Vocational Nurses 705,200
Dentists 112,300
Dental Hygienists 192,330
Select Health Care Jobs in the United States, 2013
Pharmacists 287,420
Optometrists 32,040
Chiropractors 28,850
Podiatrists 8,850
Therapists 600,660
Diagnostic technicians 1,350,000
Other technologists and technicians 599,610
Total 7,536,903
Sources: Physician data from AAMC 2013 State Physician Workforce Data Book; NP data from NCHWA NP sample survey; PA data from the NCCPA 2013 Annual Report.; All other professions from the Bureau of Labor Statistics, extracted 2/11/15.
Who work with many support staff
Nursing Assistants 1,427,830
Home Health Aides 806,710
Medical Assistants 571,690
Pharmacy Technicians & Aides 404,940
Dental Assistants 309,540
Therapy Assistants and Aides 290,700
Health Information Technicians 180,760
Select Support Occupations in the United States, 2013
Psychiatric Technicians & Aides 142,100
Phlebotomists 108,210
Surgical Technologists 97,930
Opticians Dispensing 68,390
Ophthalmic Medical Technicians 33,740
Orderlies 52,030
Other support occupations 336,870
Total 4,831,440
Sources: Bureau of Labor Statistics, extracted 2/11/15.
And with mental health and social service workers
Social workers 591,240
Social and human service assistants 355,500
Mental Health Counselors 115,580
Rehabilitation Counselors 103,840
Substance abuse counselors 83,120
Health Educators 56,720
Community Health Workers 45,800
Marriage and Family Therapists 29,060
Total 1,380,860
Select Mental Health and Community-Based Occupations in the United States, 2013
Sources: Bureau of Labor Statistics, extracted 2/11/15.
Am I sure about those numbers I just showed you? Not really. Knowing the “real” number of
health professionals is challenging
Source: National Center for Health Workforce Analysis, HRSA. Highlights from the 2012 National Sample Survey of Nurse Practitioners http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/nursepractitionersurvey/npsurveyhighlights.pdf.
Another difficult thing to know is whether we have enough providers.
Fears of physician shortages grab headlines
But experts disagree about whether the United States will face a shortage
• AAMC projects shortfall of 45,400 primary care physicians and 46,100 specialists by 20201
• Federal government (HRSA) forecasts shortage of 6,400 primary care physicians in 20202 with increased use of NPs and PAs
• We released model in July 2014 that suggests overall supply will be adequate, more pressing issue is maldistribution
1 AAMC, https://www.aamc.org/download/158076/data/updated_projections_through_2025.pdf 2 HRSA, http://bhpr.hrsa.gov/healthworkforce/supplydemand/usworkforce/primarycare/projectingprimarycare.pdf
This project is funded by a grant from The Physicians Foundation.
Our model suggests that our nation is a story of haves and have nots
Shortage/Surplus for All Visits, All Settings, 2014
Aurora, IL
New Orleans, LA
Washington, DC
Boston, MA
New York, NY
San Francisco, CA
Slidell, LA
Rochester, MN
Boulder, CO
Huntington, WV
Bangor, ME
Melrose Park, IL
Despite increasing medical school enrollment
15,000
16,000
17,000
18,000
19,000
20,000
21,000
22,000
Projected First-Year Enrollment Growth Through 2020
30% target increase (by 2015,over 2002 enrollment)
Current Schools (n=141)
Original Schools (n=125)
Survey data Projections Historical data
Chart courtesy of Clese Erikson, Association of American Medical Colleges. Source: Results of the 2013 Medical School Enrollment Survey
Resulting in nearly 9,000 additional MDs and DOs enrolled by 2018
01,0002,0003,0004,0005,0006,0007,0008,0009,000
10,000
Combined MD and DO growth since 2002
M.D. D.O.
3,990 Additional D.O. Enrollment by 2018
4,861 Additional M.D. Enrollment by 2018
Chart courtesy of Clese Erikson, Association of American Medical Colleges. Source: Results of the 2013 Medical School Enrollment Survey; 2013 AACOM Survey of Colleges of Osteopathic Medicine
Lots of attention paid to physicians but nursing workforce is 4 times in size
Key Findings After predicting a shortage a decade ago, HRSA now forecasts that nationally RN supply will outpace demand between 2012 and 2025.
Why? Nursing schools responded to previous projections and significantly increased enrollments
Source: NCHWA, BHW, HRSA: http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf.
Growth in Nurse Practitioner pipeline mirrors RN growth
7,261
6,979
6,611
6,526 6,900
7,583 8,014
8,865 9,698
11,135
12,273
14,310
16,031
5,500
7,500
9,500
11,500
13,500
15,500
17,500
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Chart courtesy of Ed Salsberg, George Washington University. Source: American Association of Colleges of Nursing and National Organization of Nurse Practitioner Faculties Annual Surveys 1Counts include master’s and post-master’s NP and NP/CNS graduates, and Baccalaureate-to-DNP graduates.
Growth in Nurse Practitioner Graduates 2001 - 2013
But it’s not just nurses. PA pipeline has also expanded rapidly
4235
4009
4337
4512
4393 4654
4989
5215 5243
5823
5979 6479
6,607
3000
3500
4000
4500
5000
5500
6000
6500
7000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Chart courtesy of Ed Salsberg, George Washington University. Source: National Commission on Certification of Physician Assistants “Certified Physician Assistant Population Trends ”; 2013 data from personal communication with NCCPA, January 2014.
Physician Assistant Growth 2001 - 2013
And so have pharmacists
7,260
7,000
7,573
7,488
8,158 8,268
9,040 9,812
10,500 10,988
11,487 11,931
12,719 13,335
14,213 14,930
4,000
6,000
8,000
10,000
12,000
14,000
16,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013*2014*2015*
Chart courtesy of Ed Salsberg, George Washington University. Source: AACP 2012 Enrollment. Data represent first professional degrees including B.S. Pharmacy, B.Pharm., and Pharm.D. *Note: Graduation projection figure based on enrollment data.
Num
ber o
f Gra
duat
es
Pharmacy School Graduation Trends 2000 - 2015
Health professions programs react independently and on different timelines
Regulation differs between states, even for same health workers
• Health workforce is mix of licensed and unlicensed health professionals
• Licensure is state function. State licensure boards determine requirements to enter practice and set boundaries on scope of services permitted
• Result—heterogeneity between states in: 1. who is required to be licensed; and
2. what services licensed health professionals can provide patients
Example 1: Some states require radiologic technologists to be licensed, others do not
What they do:
RTs use various technologies to take pictures of a patient’s body for radiologists, who interpret the images
Note: in my home state of North Carolina, hairdressers - but not RTs - are licensed
Map adapted from American Society of Radiologic Technologists; personal communication, 2/16/15.
Radiology Technologist Licensure Environment, 2014
Example 2: Nurse Practitioners are licensed in all states, but what they can do varies
Examples:
Federal regulation does not allow NPs to independently order home health for Medicare patients. Some states allow it for patients covered by other payers
Significant variation exists in prescriptive authority, who counts as a primary care provider, and whether NPs can order physical therapy, admit patients to hospitals, and sign workers’ comp claims, death certificates, and handicap permits
Map adapted from American Association of Nurse Practitioners: http://www.aanp.org/images/documents/state-leg-reg/stateregulatorymap.pdf.
Nurse Practitioner State Practice Environment, 2014
What’s the difference between licensure and certification?
• Licensure: Recognition of competence to practice a given occupation to an individual who completes required training and testing and is held accountable to practice within established standards of safety
• Certification: the action by which an authorized body evaluates and recognizes (certifies) an individual, institution, or educational program as meeting predetermined requirements, such as standards
What’s the difference? Licensure is required to practice, certification is voluntary.
Licensure determines who can and can’t do what to the patient
Definitions based on CLEAR (Council on Licensure, Enforcement & Regulation: http://www.clearhq.org/resources/glossary_general.pdf.
Education, regulation, certification requirements makes it very difficult to coordinate and align to
address workforce needs
Source: Institute of Medicine, 2014. Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press, pg S-7.
Result: we lurch from oversupply to shortage because like health care, health workforce planning is fragmented and uncoordinated
time
supp
ly Ideal intervention point
Health professions
Typical intervention point
How to smooth the cycle? Example federal vs. state roles in workforce planning
Federal Roles State Roles
Data Invest in better data and workforce projections
Invest in better data and workforce projections to illuminate regional/state variations
Strategy (Unfunded) National Health Workforce Commission was supposed to use data to advise Congress and the Administration
States seeking strategy guidance through National Governors Association and Health Workforce Technical Assistance Center.
Education Need targeted, evidence-based, investments in training (and retraining!), address maldistribution issues
Need targeted, evidence-based, investments in training (and retraining!), address maldistribution issues
Money Lead in innovation of payment policy to shape future workforce
Strategically use state appropriations and Medicaid dollars to shape workforce
Some burning health workforce issues
• Why can’t we get the numbers/models right?
• Medicare funding of GME and social accountability
• Scope of practice and payment for non-physician providers
• Workforce implications of new models of care
Questions?
Erin Fraher
Program on Health Workforce Research and Policy Cecil G. Sheps Center for Health Services Research
(919) 966-5012 [email protected]
www.healthworkforce.unc.edu
(new website to be launched March 6, 2015)