A Primer on the Health Workforce in the United States

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

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 is in health workforce? The usual professions you think of Select Health Care Jobs in the United States, 2013 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 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

Who work with many support staff Select Support Occupations in the United States, 2013 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 Psychiatric Technicians & Aides Phlebotomists Surgical Technologists Opticians Dispensing Ophthalmic Medical Technicians Orderlies 142,100 108,210 97,930 68,390 33,740 52,030 Health Information Technicians 180,760 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 Select Mental Health and Community-Based Occupations in the United States, 2013 Social workers 591,240 Substance abuse counselors 83,120 Social and human service assistants 355,500 Health Educators 56,720 Mental Health Counselors 115,580 Community Health Workers 45,800 Rehabilitation Counselors 103,840 Marriage and Family Therapists 29,060 Total 1,380,860 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 2020 1 Federal government (HRSA) forecasts shortage of 6,400 primary care physicians in 2020 2 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

Our model suggests that our nation is a story of haves and have nots Shortage/Surplus for All Visits, All Settings, 2014 Bangor, ME Rochester, MN Aurora, IL Melrose Park, IL Boston, MA Boulder, CO New York, NY San Francisco, CA Washington, DC Huntington, WV Slidell, LA New Orleans, LA This project is funded by a grant from The Physicians Foundation.

Despite increasing medical school enrollment Projected First-Year Enrollment Growth Through 2020 22,000 Historical data Survey data Projections 21,000 20,000 30% target increase (by 2015, over 2002 enrollment) Current Schools (n=141) 19,000 Original Schools (n=125) 18,000 17,000 16,000 15,000 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 Combined MD and DO growth since 2002 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 3,990 Additional D.O. Enrollment by 2018 4,861 Additional M.D. Enrollment by 2018 M.D. D.O. 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 Why? Nursing schools responded to previous projections and significantly increased enrollments Key Findings After predicting a shortage a decade ago, HRSA now forecasts that nationally RN supply will outpace demand between 2012 and 2025. Source: NCHWA, BHW, HRSA: http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf.

17,500 15,500 13,500 Growth in Nurse Practitioner pipeline mirrors RN growth Growth in Nurse Practitioner Graduates 2001-2013 12,273 14,310 16,031 11,500 9,500 7,500 5,500 11,135 9,698 8,865 6,979 7,583 6,526 8,014 7,261 6,611 6,900 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 1 Counts include master s and post-master s NP and NP/CNS graduates, and Baccalaureate-to-DNP graduates.

But it s not just nurses. PA pipeline has also expanded rapidly 7000 6500 6000 5500 5000 4500 4000 3500 4235 4009 4337 Physician Assistant Growth 2001-2013 4512 4393 4989 4654 5215 5823 5243 5979 6479 6,607 3000 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.

And so have pharmacists Number of Graduates 16,000 14,000 12,000 10,000 8,000 6,000 7,260 7,000 Pharmacy School Graduation Trends 2000-2015 7,573 7,488 8,158 9,040 9,812 8,268 10,500 11,487 10,988 12,719 11,931 14,213 13,335 14,930 4,000 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.

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 Radiology Technologist Licensure Environment, 2014 Map adapted from American Society of Radiologic Technologists; personal communication, 2/16/15.

Example 2: Nurse Practitioners are licensed in Examples: all states, but what they can do varies Federal regulation does not allow NPs to independently order home health for Medicare patients. Some states allow it for patients covered by other payers Nurse Practitioner State Practice Environment, 2014 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.

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 Ideal intervention point Health professions supply time Typical intervention point

How to smooth the cycle? Example federal vs. state roles in workforce planning Data Strategy Federal Roles Invest in better data and workforce projections (Unfunded) National Health Workforce Commission was supposed to use data to advise Congress and the Administration State Roles Invest in better data and workforce projections to illuminate regional/state variations 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)