Issue Brief

August 2001

The Health Care Workforce

"Health care is at a critical juncture...If nurses, physicians, respiratory therapists, medical technologists and scores of others who take care of our nation's ill and injured are not available, our mission will be threatened."  Testimony from the American Hospital Association before the Health, Education, Labor and Pensions Committee of the US Senate.  

Is there a problem today?
It seems to most of us that there are increasing numbers of headlines about problems in the healthcare system.  From the Institute of Medicine's (IOM) shocking report on medical errors, to recent nurses strikes in many cities, to long lines and shortened hours at our neighborhood pharmacies, something feels amiss in the healthcare system we have all grown to rely on.

What is the real story on the healthcare workforce?  Are there enough people to take care of today's sick and elderly patients and will there be enough ten years from now when the baby boomers start to join the ranks of senior citizens?

At NIHP we have undertaken a major effort to look at the issues involved in developing the health workforce for the future.  We are doing this by focusing on the health workforce in Minnesota and we will be working with people from the health care delivery system, the educational establishment, the government, and various consumer and professional organizations.  The focus of this newsletter will be to discuss what is happening to the healthcare workforce today and what efforts are being made at the national level to deal with its current problems.

The Issues
The situation in today's health care workforce is interesting.  The size and composition of this workforce is a cause for concern to both policy makers and health care professionals.  The rapid, radical, and unpredicted changes that have occurred in our health care system over the last several years make dealing with workforce questions extremely critical. 

The country has current and projected serious shortages of nurses, pharmacists, laboratory technicians and other health care workers.  The picture for physicians is more complicated.  Some health policymakers, academicians, and educators believe that the United States is headed for a physician surplus.    Others believe the competitive market forces alone will correct imbalances and bring the future supply of physicians into balance with future demand for physician services and that there is no need to intervene with policies.  Nonetheless, most experts agree that even with an ample supply of physicians there are serious distribution problems.

 In addition to these highly visible positions there are many other health care professions and not many people are looking at them.  In fact, there are 216 different health professions.  It is my hope that the work done by NIHP will help lead to some new and creative ways to help this diverse and large workforce function more effectively.  As you will see in the following sections, Congressional proposals are not dealing with the question yet.

Physicians
The IOM is in the process of doing a major study of the physician workforce. 

In 1970, there were 308,487 active physicians in the United States.  That amounted to a ratio of 151.4 physicians per 100,000 people.  By 1992 the number of active physicians had risen to 627,723, making the ratio 245 physicians for every 100,000 people.  This means that in the last two decades the supply of doctors grew at a far greater rate than the general population.  

The IOM has not concluded that we have an oversupply of physicians today although some of its members think we do, but their report concludes we will have an oversupply in the future if the growth rate does not change.   This in itself might not be a problem, but there is no firm evidence that an abundance of doctors has a beneficial effect on access, quality, or costs of health care.  A surplus of doctors does not solve the problem of maldistribution either by geographic area or specialty. Federal resources for funding graduate medical education should specifically target the maldistribution problems in order to improve the health care system. 

The maldistribution problem related to specialty versus primary care physicians has evolved since World War Two.  The expansion of federal funding for biomedical research shortly after the end of WWII contributed to American medicine becoming more hospital-based, encouraging physicians to pursue specialties.  During the 1980s and early 1990s there was a downward trend in the number of medical school graduates entering primary care residencies.  A reversal of this trend has occurred in the last 10 years with the proponents of primary care becoming more vocal and with the growing interest of managed care plans in recruiting generalists to serve as gatekeepers in the managed care system.  The reduced interest in primary care specialties during the 1980s and early 1990s was seen as a major contributor to the current national health care crisis in this country

 A further complexity is introduced into the physician supply question by the open-ended immigration of doctors and international medical graduates from other countries.  Graduate medical education is an important factor in physician supply because interns, residents, and fellows play a great role in patient care.  The number of U.S. medical graduates in training has remained stable for the last twenty years, but the number of international medical graduates (IMG) in residency training increased by 80 percent in just the five years between 1988 and 1993. 

The IOM has concluded that, "It is in the national interest to avoid an oversupply of physicians."  They recommend that policies be changed so that, while training institutions in the US continue to train foreign medical graduates, the students are encouraged to return to their homelands upon completion of that training.  Since some hospitals, particularly in inner cities, are very dependent on IMGs for residents, the IOM also recommended that -- federal and state governments take immediate steps to develop a mechanism for replacement funding for IMG-dependent hospitals that provide substantial amounts of care to the poor and disadvantaged.

Pharmacists
Unlike the situation with physicians, there is an acute shortage of pharmacists in the country today.  Last December the Health Resources and Services Administration (HRSA) released a report entitled "The Pharmacist Workforce: A Study of the Supply and Demand for Pharmacists."  This report identified and quantified the shortage.

 The HRSA study concluded that the pharmacist shortage is due primarily to an increased demand for pharmacists and their services.  The dramatic growth in the number of prescriptions prepared every day and the major expansion in the role of the pharmacist in patient care are examples of the radical changes occurring in health care in the last decade.

 According to HRSA, the number of prescriptions dispensed outside of hospitals increased 44% between 1990 and 1999.  At the same time, the number of pharmacists per 100,000 people grew just 5%.  This level of growth is estimated to remain the same over the next ten years according to a recent study published in the Journal of the American Pharmaceutical Association. 

Obviously, this disconnect between supply and demand is going to result in an increase of open positions for pharmacists.  The National Association of Chain Drug Stores estimates that the number of full and part-time pharmacist positions that went unfilled grew 159% in the two years from 1998 to 2000.  The shortage is also felt in hospitals where they are reporting 21% vacancy rates in pharmacist positions and the federal services where the pharmacist vacancy rate is reported to be as high as 18%. 

The numbers make it pretty clear that the pharmacist shortage affects every state and every setting in which pharmacists work.  The shortage not only hurts consumers, it has a negative effect on the pharmacists themselves.  Longer work hours, less flexibility, and stressful working conditions reduce job satisfaction and may prompt some pharmacists to leave the profession, thus exacerbating the problem.  And more importantly, the current difficult work environment increases the potential for medication error. 

While increasing the use of automation and pharmacy technicians can help deal with the volume of daily prescriptions, the need for professional pharmacists will persist in order to help patients in an era of comprehensive drug therapy.

Non-Physician Clinicians
Traditional non-physician clinicians (NPCs) include nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and physician assistants, with NPs being the largest in number.   It is anticipated that the dynamics affecting NPCs will have profound effects on the practice of medicine.  By 2005, the number of NPCs is projected to reach approximately 300,000, half the number of practicing physicians.  NPCs will increasingly assume tasks and responsibilities that physicians formerly considered their own.  As more physicians shift from solo practice to group practices and to large organizations, opportunities for interdisciplinary practices increase.  NPCs now perform many procedures traditionally performed by physicians and have been determined to be as cost-effective, demonstrating comparable levels of patient satisfaction when compared to physicians.  Hospitals are also considering NPCs in performing roles presently provided by residents.

Nurses
There is a definite shortage of nurses today that is only going to get worse unless serious thought and effort are put into the problem.  The nursing shortage presents a slightly different problem from the pharmacist shortage for a variety of reasons.

 The three main issues most frequently discussed when people speak of the nursing shortage are:  A shrinking supply of nurses in the pipeline to replace the large numbers who will be retiring in the next few years, insufficient faculty to train new nurses, and working conditions that undermine quality patient care and the ability to retain nurses.

Nursing is a physically and emotionally demanding career that is practiced in a complex and changing environment.  As Sister Mary Roch Rocklage of the Sisters of Mercy Health System in St. Louis recently told a congressional committee, "Health care careers have gone from favored to disfavored jobs, and from secure to insecure careers.   Women, who traditionally comprise the majority of nursing personnel, are finding other career options that are less physically demanding, more emotionally rewarding and come with a higher rate of pay."

It is estimated that there are currently 70,000 nursing staff vacancies in the U.S.  One study estimates that 50% of the registered nurse workforce is over 50 years old with the average age of working nurses at 45.  Nursing schools and training programs are experiencing annual declines in enrollment and their faculties are also aging.  Some government predictions state that we will need 1.7 million nurses by the year 2020 but only a little over 600,000 will be available. 

In addition to the problem of an aging workforce, the changing nature of the work environment has caused many nurses to leave their profession for other work.  Nursing workloads have increased with most hospital nurses reporting increases in the number of patients they have to care for and patients that are sicker and more frail.

Many nurses complain that the quality of care they are able to give has declined due to difficult working conditions.  Where these complaints occur there have been more patient falls and medication errors reported.   Further, many more nurses report increases in mandatory overtime.  There appears to be a direct link between overtime and quality of care as nurses who rate the quality of their care as poor, report working 50% more overtime than those who rate the quality of their care as excellent.  In addition, nurses who work a great deal of overtime hours report making more medication errors. 

Clearly, this is not something we want to leave unaddressed.  I serve on the Robert Wood Johnson National Advisory Committee for the study of nursing, which is a major project to develop strategies to deal with the nursing shortages.   In addition, the Agency for Healthcare Research and Quality is soliciting proposals to examine the effects of working conditions on worker health and patient safety. If these studies progress well, they should prove very helpful to health care administrators and policymakers in determining the steps that need to be taken to make the health care setting a safer place to work and receive care.

Allied Health Technicians and other Workers
The shortage problem is not limited to the health professions already described.  Many other critical professions also face shortages.  HRSA is analyzing a large number of provider types and will report on 15-year supply and demand projects for 30 occupational classifications in healthcare.  These occupations will include chiropractors, dentists, dental assistants, dental hygienists, dieticians and nutritionists, home health care aides, medical and clinical laboratory technologists and technicians, certified registered nurse anesthetists, licensed practical nurses, registered nurses, nursing aides, orderlies, attendants, occupational therapists, occupational therapy assistants and aides, ophthalmologists, opticians, optometrists, pharmacists, pharmacy technicians, physical therapy assistants and aides,  physician assistants, physicians, psychiatrists, psychologists, physical therapists, public health workers, radiology technologists, respiratory therapists, respiratory therapists, speech-language pathologist, audiologists, and social workers.

One example in this broad array of health professionals is the approaching serious shortage of medical laboratory personnel.  Vacancy rates for seven of the ten key laboratory medicine positions are at an all time high.  Vacancy rates for cytotechnologists –the people who evaluate pap smears and other cellular material—and histotechnologists –the people who prepare tissue samples for cancer biopsies—are alarmingly high at over 20%.  And in some regions of the country; i.e., the west south central region, the vacancy rate for histotechnologists is over 70%.

The story pretty much parallels the story of the pharmacists and nurses.  Laboratory personnel who entered the workforce in the 1960s and 1970s are approaching retirement just at the time the need for laboratory professionals is growing. 

While normally the solution to the problem would be to train more people, the number of medical technology programs has decreased from 383 in 1994 to 273 in 1999.  And the number of graduates in these programs has also decreased, with 3563 graduates in 1994 and only 2491 graduates in 1999.   Clearly, more needs to be done.

Some of the Proposed Solutions
There are a variety of legislative proposals floating around Congress to deal with some of these problems.  And there also are significant private sector efforts underway. 

Congressman James McGovern introduced HR 2173, the Pharmacy Education Act, on June 14 of this year to help address the pharmacist shortage. This bill amends the Public Health Act to include pharmacist services within the National Health Service Corps program of scholarships, including first-year pharmacy studies, loans, and funding. This provision should help alleviate the problem of under-servicing in certain rural areas and inner cities. It also provides grants to qualifying schools for: student and faculty recruitment and retraining, computer-based pharmaceutical education systems, and facilities construction. 

The proposal is an effort to enhance the long-term ability of schools to expand while maintaining adequate faculty.  There are also some private sector efforts to expand the supply of pharmacists, with some large chain pharmacies offering to pay tuition for pharmacists willing to work for them after graduation.

A few different types of proposals have been offered in Congress to deal with the problems in the nurse workforce.  Some of these bills amend the Fair Labor Standards Act to limit the number of overtime hours that employers may require of licensed health care employees, including nurses but not doctors. 

Other proposals directly target the nursing shortage.  One proposal offered by Congresswoman Lois Capps, establishes a new National Nurse Service Corps Scholarship program similar to the National Health Service Corps discussed in the last NIHP newsletter.  This program would provide scholarships to people seeking nursing educations in exchange for their commitment to serve in shortage areas.   It would also direct the Secretary of Health and Human Services to develop an advertising program to promote the nursing profession and encourage individuals from diverse backgrounds and communities to enter the nursing profession, and to give grants to eligible programs to increase the number of nurses.  It also establishes a fast-track nursing school faculty-training program.  A similar proposal has been offered in the Senate by Senator John Kerry.  As of August 29, Congresswoman Capps' bill had 170 co-sponsors in the House and Senator Kerry's bill had 36 co-sponsors in the Senate, so you can see how serious this matter is taken by members of Congress.

With regard to medical technologists, there already are grants available from HRSA to help attract new people to the field, especially for minorities and people in rural and underserved areas.  In addition, there has been a significant wage increase in this field, particularly in the last few years.  Pay for 9 of 10 types of medical technology positions increased significantly between 1998 and 2000, so shortages in this field may be corrected by the market.

Conclusion
There is a great deal of interest on the part of public policymakers as well as health care  practitioners in the health care workforce.  While there are many ideas floating around about how to solve some of these problems, they tend to be based on the historical design of the system and it is not clear if they will really work.  In many ways the health care system in our country is still in transition and it is not yet clear what the system will look like 10 or 15 years from now.  Futurists and observers of the American health system predict that health workforce changes will transform the health system.  Several agree that increased cooperation and strategic business relationships, information enabled processes, risk management and disease management, and competition based on quality will lead this transformation. Others forecast that the health system will need to make long term employment agreements such as 3-5 year contracts, empower consumers, develop creative ways to do risk-sharing, create community health innovations, demonstrate health improvement, and provide some level of universal coverage.

Health care workforce changes are major factors in any future health system scenarios.  That is why NIHP is working so hard with its diverse community of health care providers, educators, and participants, looking to the future for how we can develop the most effective health care workforce for tomorrow.  

 The National Institute of Health Policy Project – “Vision 2013” is underway to help shape the new health care workforce of the future.   This project is proceeding with the cooperation and support of the University of Minnesota, MNSCU (Minnesota State Colleges and Universities), the private colleges and the health care industry. 

For more information visit the Major Projects portion of the NIHP website.