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 erin_fraher@unc.edu

www.healthworkforce.unc.edu

(new website to be launched March 6, 2015)