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Chapter7-TheHealthcareWorkforce4.pptx
Chapter 7
The Healthcare Workforce
CHAPTER OBJECTIVES
Catalogue major health care professions, educational preparation and levels of credentialing
Understand roles & responsibilities of professionals in the overall health care delivery system
Highlight health care workforce policies, future expectations and implications of the ACA
Introduction & Health Professions (1)
One of largest U.S. employers; 16.4 million, 11.4% U.S. workforce
200+ occupations & professions; At 35% of workforce, hospitals are major employers (Fig. 7-1)
New vocations result from system changes, ~5.6 M new jobs in next decade, more than any other industry
Introduction & Health Professions (2)
Employment growth highest among health plans, ambulatory clinics, home health, offices of practitioners
Specialized positions result from medical advances, but reduce flexibility & increases costs
Growing acceptance of multi-skilled professionals, esp. in hospitals combining roles in related fields.
Credentialing, Regulating Health Care Professionals (1)
Government regulation necessary to protect citizens from incompetent, unethical practitioners. States are primary regulators; variations from state-to-state
~50 occupations regulated by:
1. State licensure
2. Certification
3. Registration
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Credentialing, Regulating Health Care Professionals (2)
The “downsides” of regulation
Restrictions limit health care organizations’ use of personnel and abilities to innovate in patient care
Restrictions influence professional educational programs to tailor curricula to testing requirements
States revising credentialing to provide more flexibility to fast-changing technology
State Licensure (1)
Most restrictive type of regulation; restricts entry into fields of practice
State laws define practice scope, education and testing requirements.
Prevents use of professional titles without meeting predetermined qualifications
Licensure boards: concern for setting standards, assessing competence for entry to fields of practice; power to censure, warn, revoke
State Licensure: Shortcomings
Assesses only qualifications on entry to field
Does little to assess continuing competence; only continuing education courses
Lax discipline; rarely censure or revoke licenses
State/National Certification
State or voluntary professional organizations attest to education and performance abilities, e.g. national boards; Commission on Accreditation of Allied Health Education Programs.
No legal basis to prevent incompetent or impaired practice; only probation or revoking certification
Payers or employers insist on certification.
Registration
Begun by various professions as a means to network for jobs among employers, general public
Registration requirements range from listings of individuals to national registration programs requiring educational & testing qualifications, e.g. registered dietitian.
Physicians (1)
137 U.S. Medical Schools
17,364- 2011 graduates
26 Colleges of Osteopathy
4,200 annual graduates
7% of all U.S. physicians (63,000)
MDs, DOs share same privileges
Medical students ~49% female, ~38% minority
Physicians (2)
Post-graduate training
Most states require at least one year for licensing; professional standards require a minimum of 3 years of residency training to practice a specialty
Residency may range up to 8+ years;
Fellowships required for certification in subspecialty areas
Physicians (3)
Gap of 5,000 1st year residents filled by graduates of foreign medical schools
6,000 foreign nationals enter U.S. practice per year
25% of U.S. practicing physicians
~1300 U.S. citizens attend foreign medical schools & return to U.S. each year
35% of 700,000 practicing U.S. physicians are primary care: Internal medicine; Family practice; Pediatrics
Nursing (1)
Early U.S. Nursing
First professional training program: 1861, Philadelphia Women’s Hospital
Pre-WWI, 3 domains: public health, private duty, hospital
Public health elite: TB & infant care
1920: 70% worked private duty, half in homes and half for private patients in hospitals; few employed in hospitals
Nursing: Post WWI
Hospital care & training emphasized; hospital-based schools of nursing proliferated to provide sources of low-cost labor; social & public health aspects were subjugated to image as symbols of national sacrifice & efficiency, deferential to physicians
Nursing leaders promoted high-quality nursing schools, preferably associated with universities
Nursing: Training & Education-RNs
2 yr. associate degree
2-3 yr. hospital diploma programs –now defunct
4-5 yr. bachelor degree at university/college
Specialization followed medicine starting in 1950s: By 1960s, masters and doctoral level preparation for teaching, advanced practice fields; clinical nurse specialists
Nursing: Employment & Education Trends-RNs
2010 report: 3 M+ RNs; 84.8% actively employed; increase of 1.5 M 1980-2008; 1/3 of increase due to importation of foreign-born graduates
Hospitals are primary employers, followed by ambulatory care and Community/public health (Table 7-2)
Nursing: Employment & Education Trends-RNs
~90% receive basic education in an institution of higher education (often ADN) from community colleges compared with 20% in 1960; graduate- degreed nurses now comprise 13.2% of all RNs, twice the percent reported in 1988.
> 180 schools offer doctoral programs: DNP, DNS, DNSc, DSN and PhD.
Nursing: Employment & Education Trends-RNs
Hospital consolidations, fiscal pressures created hospital nursing stressors: sicker patients, higher nurse-to-patient ratios, supervision of lesser-skilled staff
Average RN age of 46 years leveled off in 2008 with recent increases in new graduates
Innovations of RWJF, sign-on bonuses, accelerated programs to address shortages
Licensed Practical Nurses
Under supervision of RN or MD
One-year training in ~1,100 approved technical schools, vocational schools, community colleges, including classroom & supervised clinical practice
State license exam required
Hospital positions decreasing; other settings, e.g. nursing homes, residential care increasing.
Overall employment expected increase of 22% by 2020.
Nurse Practitioners
RNs with advanced education, clinical experience; origins in 1960s due to MD shortage
Most have master’s degrees; national certification required; states prescribe scope of practice: 400 accredited masters & 100 accredited post masters programs
Specialize: e.g. neonatal, pediatric, school, adult, family, psychiatric, geriatric, obstetric, surgical, emergency
Cost effective, highly regarded; growing demand
Clinical Nurse Specialist
Developed in response to highly specialized medicine
Focus on highly complex, sickest patients
200+ masters programs for specialist preparation
Dentistry (1)
Early practice by barbers, blacksmiths & MDs
First school chartered in 1840 with 2-year program; by 1884, 28 schools, most privately owned; by 1900, most states required licensure
1926: Critical Carnegie report reorganized dental education.
WWII: recruits’ poor dental health raised public health awareness; Selective Service eliminated all dental standards
1940s: Public health dentistry est. by U of Michigan; dental public health now a recognized field with American Board of Dental Public Health
Dentistry (2)
1948: National Institute of Dental Research est. by U.S. Public Health Service, incorporated into the NIH
By 1980, 100 M Americans had insurance for routine & specialized services.
64 dental schools, 2010- 4,996 graduates; confer DDS or DMD; Women: 50% of school graduates
Minorities ~12% of school enrollees; recruitment tactics underway in many venues
Dentistry (3)
Specialties (83% of 155,000 are generalists)
1. Dental public health
2. Endodontics
3. Oral & maxillofacial pathology
4. Oral & maxillofacial radiology
Oral & maxillofacial surgery
Orthodontics & dentofacial orthopedics
Pediatric dentistry
Periodontics
Prosthodontics
Dentistry: Trends
Recognition of Dental Anesthesiology under review in 2012 by the ADA as new specialty
Decline of 1200 graduates per yr. since 1980
Operates as “cottage industry” unaffected by managed care, health reforms; most in solo practice serve only paying patients; many low-income are underserved; absent dental “safety net.
Pharmacy (1)
Practice dates to ancient times
Colonial U.S.: Hospital pharmacists were apprentice MDs; separated in 1765
American Pharmaceutical Association founded 1852; now, 85 U.S. colleges of pharmacy
Employment growing: aging population; increasing involvement in clinical decisions and physician/nurse/patient counseling
127 accredited schools grant Pharm.D in 6 year programs; License requires internship & state exam
Pharmacy (2)
~12,000 graduates/yr.; ~275,000 active; employment demand will exceed supply through 2020
Board of Pharmaceutical Specialties certifies specialists in: nuclear, nutritional support, oncology, pharmacotherapy, psychiatric, ambulatory care, critical care, pediatric pharmacy
43% work in commercial community practice; 23% in hospitals; 34% work in government, for insurers, for long-term care facilities, other institutions.
Podiatric Medicine
Diagnoses, treats diseases, injuries of lower leg and foot.
Prescribes drugs, lab tests, performs surgery
9 accredited U.S. schools; 4 yr., post-baccalaureate education; many opt for 3-4 years post-graduate training to achieve board certification in specialties: primary care podiatric medicine, diabetic foot wound care & footwear, limb preservation & salvage, or podiatric surgery
Licensure required in all states
Chiropractors
Treat the whole body without drugs or surgery; believe spinal misalignment and nerve irritation interferes with normal body functions
15 accredited programs, 2 accredited institutions
Applicants require 90 undergraduate credit hours
All states require licensure
52,000 current practitioners; projected increase to 67,000 by 2020 due to aging population demand
Achieve comparable results with MDs for back pain conditions.
Medicare and many private health plans’ coverage
Optometry
Doctors of Optometry (ODs) diagnose vision problems, eye disease, prescribe treatment, fit eyeglasses, contact lenses
20, 4-year colleges graduate 1,300/year; 1 yr. residencies for specialization, e.g. family practice, pediatric, geriatric, low-vision, cornea & contact lens, etc.
Over 34,000 licensed practitioners
State license requires written & clinical exams
Health Care Administrators
Organize, direct, coordinate services in hospitals, clinics, nursing facilities, physician practices
Bachelor, master and doctoral programs; certificate, diplomas
70 schools have accredited masters’ programs
Most employed in hospitals, clinics, physician practices
Allied Health Personnel
200+ occupations supplement work of physicians, dentists, other health professionals within 80 allied health fields
Four categories
Laboratory technologists & technicians
Therapeutic science practitioners
Behavioral scientists
Support services
I. Laboratory Technologists & Technicians
State licensed; rapid growth & diversity; National Accrediting Agency for Clinical Laboratory Sciences accredits 581 programs; 330,000+, > 50% hospital employed.
Analyze body fluids, tissues, cells, chemical contents, bacterial growth, match blood for transfusions
Technologists: bachelor degrees
Technicians: associate degrees
Radiologic Technology
Supervised by physician radiologists; Joint Review Committee on Education in Radiology accredits >700 programs
Training 1-4 years: certificates, associate & bachelor degrees
Obtains, interprets radiographs, fluoroscopic images, ultrasound images, CT Scans, MRI scans, PET scans
Nuclear Medicine Technology: 1 year hospital certificate programs for radiologic technologists, RNs or allied health graduates; use of radio active drugs and detection equipment
Nuclear Medicine Technology
1- year hospital certificate programs for radiologic technologists, RNs or allied health graduates meeting federal standards for use of radioactive drugs and detection equipment
50% of states require licensure
Professional certification or registration is voluntary
II. Therapeutic Science Practitioners
Physical Therapists
Occupational Therapists
Speech Language Pathologists
Physician Assistants
Physical Therapists (PTs)
State license; doctoral degrees the norm; 211 accredited programs
Numerous specialties
Graduate accredited colleges; complete internship
Treat injuries, disabilities, improve function; collaborative role
Employment: Hospitals, rehab centers, nursing homes, private practice
Occupational Therapists (OTs)
Various regulation in all states, ranging from license to registration
Masters degree required; doctoral degrees offered.
Assist recovery from injuries to recover living skills, work abilities; plan educational, vocational, recreational activities
Employment: Hospitals, nursing homes, community mental health, adult day care programs, rehabilitation facilities
Speech Language Pathologists
All states regulate; Master’s degree in speech language or audiology required for license in 27 states
253 colleges & universities offer programs
Evaluate, treat patients of all ages with communicative, swallowing disorders
Employment: Hospitals, long term care facilities, schools/universities (~50%), clinics
Expanding employment for aged population and children with communication disorders
Physician Assistants (PAs)
1961: Duke University initiated for military corpsmen, medics
All states grant treatment privileges
Many specialties; diagnose, give therapy, counsel, prescribe drugs & refer under MD supervision
165 programs: many offer masters degrees, some offer baccalaureate degrees; a few associate degrees
Rising demand
III. Behavioral Scientists
Social Workers & Rehabilitation Counselors
Provide social, rehabilitative, psychological, community education resources.
Focus on health maintenance, adjustment to disabilities, prevention
Social Workers
Bachelor’s degree required; master’s degree often the employment standard
480 accredited bachelor’s, 280 master’s programs; 100 doctoral programs prepare for advanced practice and/or research
Counsel patients, families on personal, economic, social problems of illness, disability; arrange community resources
Growing demand in gerontology, substance abuse, mental health fields
Rehabilitation Counselors
Bachelor’s/Master’s degree required for state license or certification
Provide counsel, emotional support, rehabilitation therapy; test abilities, skills levels, interests & psychological state
Develop training plans to maximize functioning & prepare for employment.
IV. Support Services: Health Information Administrators
Bachelor’s degree in health information administration is entry-level requirement
Medical record administration in hospitals, other health facilities; maintain systems to store & retrieve of patient data for financial, legal and research purposes
Projected major future increase in employment; ARRA est. training centers in variety of related practices to support EHR implementation
Alternative Therapists (1)
Medical science has fostered public’s interest in “alternative” approaches
“A group of diverse medical and health care systems, practices and products that are not presently considered a part of conventional medicine.”
Complimentary Medicine: adds to mainstream medicine
Alternative: outside the mainstream
NIH Center for Complementary and Alternative Medicine est. in 1998; ~ 38% of American use forms of CAM; $ 34 B expenditures/year
Alternative Therapists (2)
National Center for Complimentary and Alternative Medicine (NCCAM) Surveys to estimate extent of use
International study of traditional medicines
Studies of medicinal herbs
Studies of unusual therapies, e.g. telepathic healing
Factors that Influence Demand for Health Personnel (1)
Medical, scientific advances that increase longevity, chronic care needs and survival of traumatic events
Physician supply: almost all other providers depend on physician support
Technologic advances increase specialists & eliminate other classes of workers, e.g. laboratory automation
Home care increases with aging population; reforms shift more care to community settings; workforce demand and technical capabilities increase
Factors that Influence Demand for Health Personnel (2)
Corporatization of health care
Hospital consolidations/mergers; vertical integration into care continuums
Physician practice arrangement changes: solo->group-> hospital employment
New provider organizations, e.g. ACOs
Reforms increase “users” by 25 M+
Healthcare Workforce Issues & the ACA (1)
Association of Academic Health Centers defined workforce issues in 1994: central to health reforms:
Adequacy of supply; geographic distribution; underrepresented minorities; future quality & relevance of professional schools’ programs; costs of education; competency testing; re-defining roles as technology changes; faculty supply
National Health Care Workforce Commission
Healthcare Workforce Issues & the ACA (2)
ACA responses to issues with federal support for:
Loans and scholarships for targeted professions in underserved areas
Cultural competency training
Minority recruitment
Primary care residency training
FQHC expansions
Community mental health & primary care integration
The Future: Complexities of National Health Care Workforce Planning
Until today, no national comprehensive planning
Stakeholders with different, conflicting priorities in education, training, regulation, financing etc.
Absence of uniform national & state data severely confounds future predictions of need
Demographics, consumer demands, new disease knowledge, delivery & reimbursement reforms will require workforce role changes & adaptations
