Everything you wanted to know about the health professions, but were afraid to ask
Edward O’Neil, Ph.D, MPA, FAAN Professor Family and Community Medicine and Dental Public Health Director of the Center for the Health Professions, University of California, San Francisco
HTTP://FUTUREHEALTH.UCSF.EDU
Center for the Health Professions University of California, San Francisco
For more information, please contact: UCSF Center for the Health Professions 3333 California Street, Suite 410, San Francisco, CA 94118 Phone: 415/476-8181 HTTP://FUTUREHEALTH.UCSF.EDU eoneil@itsa.ucsf.edu
Why Workforce?
• • • • • 60-70% of health care is labor costs Big part of any employment sector Limitations to access and spur to cost increases Represent opportunity for many State action through professional regulation, education, health regulation
Who will provide care?
• Supply of Selected Health Professions, 2000
– – – – Dentists Pharmacists Nurses (RNs) Physicians
Physicians
154,000 196,000 2,600,000 710,000
Dentists
Gender Distribution Percent Female, 2000
Pharmacists
46% 14%
22%
Health Care Workforce General
4
Percent Change from Last Period
Growth in Total and Health Services Employment
3
2
Health
1
Total
0
-1
pr -0 0 l-0 1 0 n99 99 n9 p0 b0 ov Se Ju ec D 01 9 1 Fe
Ja
Ju
-2
Source: U.S. Department of Labor, Bureau of Labor Statistics.
N
A
Why Workforce?
4.1 million other workers 2.1 million health professionals
Health professions & Occupations
8.5 million health professionals
Health service settings
Health professional Health service setting
Other work settings Total
Other Workers 4,064,745
124,713,945 128,778,690
8,485,358
2,103,557 4,064,745 14,653,661 139,367,605
Total 12,550,104
126,817,502 139,367,605
6.1%
1.5% 2.9% 10.5% 100.0%
8,485,358
2,103,557 10,588,915
Health professionals working in health service settings
Health professionals working in other settings Other workers in health service settings US health workforce US civilian labor force
Source: Bureau of Labor Statistics, 1999
Why Workforce?
Composition of Health Services Employment by Occupation, US, 1998
LPNs 5%
Physicians 4%
Nursing aides orderlies and attendants 10%
Other health professions 29%
RNs 16%
Non-health professions 36%
Source: Bureau of Labor Statistics
Why Workforce?
Home health 6% Medical & dental labs. 2% Other 4%
Health Services Employment by Place of Work, US, 1998
Hospitals 44% Offices & clinics 27%
Nursing & personal care facilities 17%
Source: Bureau of Labor Statistics
Regional Variation in RN Supply, 1999
400-500 RNs/100,000
500-650 RNs/100,000 650-800 RNs/100,000
800-1000 RNs/100,000
Under 400 RNs/100,000
More than 1000 RNs/100,000
Nursing: Supply
Nursing: Supply
0 0
Percentage
Are there enough?
Projected Demand to Supply of RNs 2000-2020
0
0 -11 -8 -10 -19 -21 -34
-6 -7 -12 -20 -29
-10 -20 -30 -40 -50
17 K 121 K
NC CA 2015 2020
808 K
US 2000 2005
-45
2010
Source: Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 July 2002 U.S. DHHS, HRSA, BHPr, National Center For Health Workforce Analysis
Internal Drivers – Pay
Source: Bureau of Health Professions, RN Sample Survey, 2000.
Internal Drivers – Aging workforce
Source: Bureau of Health Professions, RN Sample Survey, 2000.
Nursing: Supply
Who will provide care?
US Candidates for RN exam
Number by Training Program
100000 80000 60000 40000 20000 31195 32278 31828 30142 28107 26048 0 7335 6346 5240 3978 3161 2679 1995 1996 1997 1998 1999 2000 Diploma Baccalarate Associate 57908 55554 49045 49045 45255 42665
Decline of 26% 1995 to 2000
* First time candidates, US educated only
Source: National Council of State Boards of Nursing, www.ncsbn.org
Who will provide care?
RN pass rate for all candidates, 1994-2000
85 80 75 70 65 60 1994 1995 1996 1997 1998 1999 2000 82.4 79.9 76.6 76.2 71.8 70.8 68.8
Source: National Council of State Boards of Nursing, Inc. www.ncsbn.org
What is driving the shortage?
Source: Registered Nurse Population, March 2000, US DHHS, HRSA, BHPr, Division of Nursing, 2/22/02
Costs of Replacement Labor
Sources of Replacements Replacement Costs per FTE
$102K Float Pool 20% Overtime 35%
120 100 80 60 40 20 0
$80K
$82K
Dollars in Thousands
$64K
Staff RN
Float Overtime Agency Pool
Agency 45%
Source: Center for the Health Professions, UCSF, 2003. Analysis of selected 600 Bed Hospitals
Nursing: Issues & Pressures
• • • • • • • • Recruitment Retention Implementation of staffing ratios Outdated work environment Nurses viewed as commodity Scope of practice ceiling and floor issues Limited workforce data Limited leadership
Source: O’Neil E, Kimball B. Health Care’s Human Crisis: Nursing. (Princeton: Robert Wood Johnson Foundation, 2002)
Basic Elements - Physicians
PHYSICANS Supply : 1950-2020
1400
Physicians per 100,000 pop
300
260
High/Low Demand Estimates
1200
274
266
PHYSICANS (000)
236 195 837 731 601 453 881
250 200 150 100 50 0
1000 800 600 400
142
141
155
219
259
323
200 0 1950 1960 1970 1980 1990 2000 2010 2020
Source: Lohr KN, Vanselow NA, Detmer DE. The Nation’s Physician Workforce: Options for Balancing Supply and Requirements.National Academy Press, Washington DC: 996. 4.
Basic Elements - Physicians
Practice Settings Specialists, CA 2001
Clinic
Kaise 15 r >50 6
1
Solo
46
11-50
5
26
2-10
Source: Center for the Health Professions, 2003
Basic Elements - Physicians
Practice Settings Primary Care, CA 2001
Kaise r >50
4 21
Clinic
34
Solo
11-50
6 8 24
2-10
Source: Center for the Health Professions, 2003
Medicine: Supply
Are there enough?
Ratio of Active CA Physicians to 100K Pop
200
185/100K
180 160 140 1994 1997 2000
177
182
190
145/100K
Source: UCSF Center for the Health Professions, 2001
Medicine: Distribution
How to diversify the workforce?
Asian/PI
3%
12%
20% Asian/PI
Other
Hispanic
4% 3% 70%
31%
Hispanic
50%
Black
7%
Black
White/Non H
White/Non H
CA Population, 2000
CA Physician Population, 2000
Source: California’s Physician Workforce, Center for the Health Professions, UCSF, 2001.
Medicine: Demographics
Median Income in thousands, 1998
200
100
132
249
0 FP Cardiology
33
Mean CA Income
How they practice
Physicians per 100,000 Population
250
200
Supply of Practicing Physicians in the US
190 166 149 130 115 115 94 59 79 65 50 51 55 60 56 123 106 67 63 140 203
150
100
50
0 1965 1970 1975 1980 1985 1992 Total 2000 Generalists Specialists
Source: COGME, 1996
How they practice
Family Practice Positions Offered and Filled With US Seniors, 1991 - 2001
3500 3000 2774 2500 2467 2486 2589 2276 2340 2179 2024 1833 1516 2081 1850 1500 1000 500 0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 1636 1374 1398 3137 2941 3262 3293 3265 3206 3096
Positions
2000
Offered
Filled
Medicine: Issues & Pressures
• Stable medical school numbers, graduates • Rising physician:population ratios • Decades of rising number of residency programs recently stalled by BBA • Geographic maldistribution – rural shortages • Gender and race/ethnicity imbalances • Some specialty shortages • Primary care/specialist debates • Limited acceptance of some insurance
Pharmacist Shortage
Number of Prescriptions in Ambulatory Settings
3 2.5 1.9 2 1.5 1 0.5 0 1990 1999 2.8
Source: Tina McRee, Pharmacy Staffing a Silent, but Critical Concern, Center for the Health Professions, UCSF, 2003.
Billions
Pharmacist Shortage
Number of Pharmacists to 100,000 population, US and CA
80
US
Pharmacists
70 60 50 40 1973 1991
IL
1998
Source: Tina McRee, Pharmacy Staffing a Silent, but Critical Concern, Center for the Health Professions, UCSF, 2003.
Factors Driving Pharmacist Shortage
• Increasing use of prescription meds
– – – – – Aging population More and better coverage New drugs DTC More professionals, prescribing more Retail chain competition –facilities and hours More time verifying coverage
•
•
Market demands
– –
Changing pharmacist practice
– – – More complex drugs More clinical pharmacy More opportunities outside of care More females PharmD
•
Workforce
– –
Source: Center for the Health Professions, Pharmacy Leadership Institute, 2003
Allied Health Professionals
• Over 215 different health professionals that are either registered, licensed, certified or in some way credentialed by a public agency. • Range from informal or a few weeks of training to masters entry physical therapist. • Incomes range from a minimum wage to well beyond the average for general medicine. • Number around 5.5 to 6.5 million workers
Source: Center for the Health Professions, Pharmacy Leadership Institute, 2003
Allied Health: Supply
• There are 10.5 million health care workers in the U.S. Nearly 60% of them are allied and auxiliary health care workers. • They provide the bulk of direct health care services--at home, in the hospital, and nursing homes. • Many are women and represent ethnic and racial minorities and recent immigrants
Allied Health: Supply
Allied
200 + professions – Therapeutic – Diagnostic – Informational – Environmental –
Auxiliary
– Work in health care delivery setting – No degree or certification in health care Examples: • Food service • Laundry • Environmental services
Examples: – • Clinical laboratory scientist • Diagnostic imaging technician • Dietician • Home health aide • Medical assistant • Medical records technician • Physical therapist
Hospital Vacancy Rate
2002 National Vacancy Rates
16 14 12 10 8 6 4 2 0 13 15.3 12.9 11.3 9.5
Percent
RN
LVN
Lab Tech
Rad Tech
Resp Tech
Source: AHA, Analysis by Center for the Health Professions, UCSF, 2003.
Declining Capacity
Number of National Training Programs
900
Number
700
Rad Tech
500
Lab Tech Resp Tech
300 1985 1990 1995 2000 2003
Source: AMA, Center for the Health Professions, UCSF, 2003.
Allied Health: Supply
• Projected CA shortages in:
– – – – – Radiology technicians Surgery technicians Laboratory technicians MAs CNAs 47%* 39% 76% 59% 77%
*Projected percentage shortfall of in CA in 2010
Source: Alpine Health Corps analysis of BLS data for CA, 5/2/02
Allied Health: Pressures & Issues
• Workforce Problems
– Struggle to attract and retain students/workers – Gap between education and industry needs – Increase in need for leadership, critical thinking, computer skills – Changing nature of work – Changing role of unions – Aging workforce in certain allied professions
• Worker Experiences
– – – – – Poorly defined job expectations Low pay, lack of benefits High rates of turnover Inadequate training High rates of work-related injury – Lack of opportunities for advancement – Lack of recognition
Dentistry: Supply
Dentists per 100,000 U.S. Population 1950-2020
(Valachovic et al. JDE, 2001)
61
Are there enough?
59.5
59 57 55 53
52.7 51.5
51 49 47 45
49.0
1950
1960
1970
1980
1990
2000
2005
2010
2015
2020
Actual
Projected
Source: Bureau of Health Professions, HRSA, DHHS. Data from the Eighth Report to Congress 1991 and unpublished reports.
Dentistry: Distribution
MSSAs with a Shortage of Primary Care Dentists: California Counties, 1998
Dentist-to-Population Ranges
Non-Shortage Shortage No Dentists
Dentistry: Demographics
First-Time, First-Year Minority Enrollees in U.S. Dental Schools: 1990-1999
(Valachovic et al. JDE, 2001)
1200 1000 800
971
576
600 400 200 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
245 215 15
205 174 25
Asian/Pacific Islander Hispanic/Latino
Source: American Dental Education Association
Black/African-American Native American/Alaska Native
Dentistry: Pressures and Issues
• Ratio of dentist-to population is decreasing • Dentistry is the least diverse of the health professions • Financial incentives for private practice are high, very small percentage of dentists work in the public sector • Professional incentive programs to serve the underserved are few and have mixed results • Dentists have enjoyed an increase in net income indicating adequate demand for current services • Large portions of CA’s population does not receive care • Underserved populations suffer a disproportionate share of dental disease, but are least likely to attain services • Mismatch between delivery and need
Complementary and Alternative Health Care: Naturopathic practice
• Naturopathic Medicine
– – – – – – – – – – – Regulated 12+ states; 1365 licensees (2000) Varied practice acts CA: not regulated; estimated 50 practitioners 6 schools nationwide; growing enrollments Unknown supply/demand Limited demographics Not regulated; estimated 3000-4000 practitioners US (2000) California: estimated 660 practitioners (2000) 12+ schools, programs nationwide; growing enrollments Unknown supply/demand Limited demographics
• Naturopathy
Source: UCSF Center for the Health Professions, 2001
Complementary and Alternative Health Care: Midwifery
• Direct entry (lay) vs. Certified Nurse Midwife • Direct entry in California
– – – – – – 140 licensed 100 estimated active 100 estimated unlicensed Main practice setting: home Limited demographics MD supervision requirement limits practice, growth
• Direct entry in US
– Growing demand – Washington state model
Complementary and Alternative Health Care: Acupuncture
• • • • • • • • CA: 8000 licensed practitioners (8th state to license) Evolved board and regulatory system Estimated 1/5 –1/4 of US total Limited demographics: High white, Asian representation Unknown supply/demand; 660 took exam July 02 Geographic distribution unknown main practice setting: office Issues:
– National standards for entry to practice – Interprofessional collaboration with MDs, others – Implementing AB 1943 (Chu) (2002)
CAM: Issues & Pressures
• • • • • Lack of consistent regulatory structure Competition with existing professions Growing demand Lack of consumer information Intra-professional conflict
Who will provide care?
Professional Supply : 1950-2020
Professionals to 100,000
290
Physicians per 100,000 pop
260 236
274
266
240 190 140 90 40
142 155 141 195
Pharmacists per 100,000 pop Dentists per 100,000 pop
51.5
49.4
49
62 53.5
68 59.5
71 58.4
75 57.3
52.7
1950
1960
1970
1980
1990
2000
2010
2020
Source: Lohr KN, Vanselow NA, Detmer DE. The Nation’s Physician Workforce: Options for Balancing Supply and Requirements.National Academy Press, Washington DC: 996. 4., HRSA, JDE
Who will provide care?
US Nursing Baccalaureate School, MD, DDS Enrollments and Graduations, 95-00
73000 63000 53000 43000 33000 23000 13000 3000
RN Graduation 23058 22423 17024 16904 Pharm Graduation
DDS Entry
73988 69426 65219
RN Enrollment
62235
59671
58384
22868 16844 7950 4273
21813 16790 7930 4297
MD Graduation
20109 16856 7900 4302
18720 16813 4314
7898 4000
7905 4102
1995
1996
1997
1998
1999
2000
Source: American Associations of Nursing, www.aacn.org
What Is Going On Now
• • • • • • • • Increase supply – recruitment Increase supply – pipeline Change work environment Improve understanding of value of worker Change utilization and compensation model Create new regulatory standards Improve data on workforce Strengthen leadership at all levels
Source: O’Neil E, Kimball B. Health Care’s Human Crisis: Nursing. (Princeton: Robert Wood Johnson Foundation, 2002)
How to frame the needed changes
High
Start Over
Complexity
Reinvent Improve Scramble
Low
Short
Time
Long
Source: O’Neil E, Kimball B. Health Care’s Human Crisis: Nursing. (Princeton: Robert Wood Johnson Foundation, 2002)
What We Can Look Forward To
• Continued push to regulate nurse staffing
– – – – CA and nurse ratios Aiken, et al IOM and Patient Safety JACHO
• Efforts to alter the practice model
– Teams – RN leadership role
• Technology – Labor substitutes
– Fewer, better trained RNs (Masters entry?)
Ten Tech Trends –
Earlier intervention new delivery system Consumer acceptance/demand new technology Cancer repositioned In patient cardiac services decline 24x7 access Workforce shortages mitigated Smarter/smaller surgeries Long term care management Customized drug therapies Targeted mental health Dx and Rx
Source: Joyce Berger, Health Technology Center
What We Can Look Forward To
• More magnetic environments
– Focus learning and problem solving on real problems – Build health into the ethics of the culture – Enhance professional and team relationships- focused on real problems – Create context for cultural competence – Tie this to career and education ladders, which are tied to corporate strategic goals
What We Can Look Forward To
• More labor management partnerships
– KP SEIU 250 – HHC SEIU 1199 – What is delivered
• New providers of education
– Apollo – Advisory Board
What We Can Look Forward To
• Continued internecine warfare
– 2 year – 4 year – RN – Masters – Labor – management
• Some very competitive places that figure out how to release core competency of nurses by…
Move nursing to strategic level
• Moving from commodity to value proposition
– Position RNs to add value – Articulation of nursing value across a care continuum – Nurse driven cost consciousness and control
Leverage RN skills into the system?
RN Core Capabilities – care management – psycho-socialbehavioral perspective – population - systems context – service orientation – cost effectiveness
Demands of the Emergent, but Inarticulate System of
Care
Barriers to leveraging RN skills into the system?
Barriers
– lack of integration in system – internecine conflict in nursing – inadequate financial knowledge – entitlement
Where will it happen?
• Systems that act like systems • Places where labor and management can work together • Rare sites where fully integrated nurse professional groups emerge • Some for profit staffing traveler transitions
Center for the Health Professions University of California, San Francisco
For more information, please contact: UCSF Center for the Health Professions 3333 California Street, Suite 410, San Francisco, CA 94118 Phone: 415/476-8181 HTTP://FUTUREHEALTH.UCSF.EDU eoneil@itsa.ucsf.edu