Understanding and Managing Health Workforce Shortages

1. Understanding and Managing Health Workforce Shortages Dr. P.J.Maddox Center for Health Policy Research & Ethics GEORGE MASON UNIVERSITY December 14, 2001

2. Overview of Presentation • Recent Developments and Trends • Challenges and Opportunities • The Health Workforce: Overview • Implications for Management of Healthcare and Social Service Organizations • Strategies

3. Workforce Affects Quality, Cost and Access to Health and Social Services • Health & social systems are as good as the workforce (availability and competence) • High turnover, difficulty recruiting and worker dissatisfaction are endemic system problems that must be addressed

4. Factors Contributing to Workforce Shortages • Demand increasing faster than supply • Supply decreasing • Mismatch of the demographics/skills of the workforce given populations • Lags in educational sector response • Relatively low return on educational investment • Characteristics of the occupation/job • Low unemployment, competition for workers

5. Developments Impacting the Health Workforce • Aging of the US population • Weak economy • The changing health care system and the evolution of managed care (shift to ambulatory) • Career patterns of women • The changing role of physicians • More knowledgeable and demanding consumers/advocates • Increased attention to quality and safety (medical errors and outcomes)

6. Cross Cutting Issues • Aging of the health & social service workforce • Geographic distribution of health personnel • Under-representation of minorities in the workforce • Financing of health care (shrinking operating margins) • Service delivery and structural changes • Public health workforce

7. As Number of Elderly Increase, the Demand for Health & Social Services Increases Population 65 thru 84 Population 85 and older

8. However, this occurs against the backdrop of maldistribution & Workforce Shortages… • Registered Nurses • Direct Care Workers, Including Home Health Aides And Nursing Home Aides • Pharmacists • Radiology Techs • Mental Health Workforce • Dentists (maldistribution) • Physicians (maldistribution)

9. Health professions & Occupations 4.1 million other workers 2.1 million health professionals 8.5 million health professionals Health service settings More Than 1 in 10 Americans Works in Health Care or is a Health Professional Bureau of Labor Statistics, 1999

10. Composition of Health Services Employment by Occupation, US, 1998 Source: Bureau of Labor Statistics.

11. Hospitals Employ over 40% Health Services Employment by Place of Work, US, 1998 Source: Bureau of Labor Statistics

12. TRENDS in the SUPPLY AND DEMAND for REGISTERED NURSES

13. Employment Setting of Registered Nurses * Includes occupational and school health settings Source: National Sample Survey of Registered Nurses, DoN, BHPr, HRSA, DHHS, Mar 2000

14. 1996 About 2.6 million RNs Over 2.1 million work in nursing 95.1% women 27% Diploma 32% ADN 31% BSN 10% Master’s or higher 2000 About 2.7 million RNs Over 2.2 million work in nursing 94.6% women 23% Diploma 34% ADN 33% BSN 10% Master’s or higher REGISTERED NURSE POPULATION MARCH 1996 AND 2000 Source: National Sample Survey of Registered Nurses, DoN, HPr, HRSA, DHHS.

15. Overall employment and RN Employment in Hospitals has Risen far Faster Than Admissions or Adjusted Patient DaysPercentage change in RN, LPN & total FTEs, US community hospitals, 1990-1999 Source: AHA

16. Trend in Registered Nurse Employment Status Source: National Sample Survey of Registered Nurses, DoN, BHPr, HRSA, DHHS, Mar 2000

17. AGE DISTRIBUTION OF RNs 1980, 1996 and 2000 Source: National Sample Survey of Registered Nurses, DoN, BHPr, HRSA, DHHS.

18. The RN Workforce is Characterized by Declining Entrants and an Aging Population Age Distribution of the RN Workforce in 1980 and 2000 Source: National Sample Survey of Registered Nurses, DoN, BHPr, HRSA, DHHS.

19. Trend in New Entrants and Losses to the RN Population, 1988-2000 1992-1996 1988-1992 1996-2000 Source: National Sample Survey of Registered Nurses, Division of Nursing, BHPr, HRSA.

20. 1996 Over 2.1 employed in nursing 94.6% women, 5.4% men 89.1% of RNs white non-Hispanic Average age of employed RN is 42.3 2000 Over 2.2 million employed in nursing 94.1% women, 5.9% men 85.9% of RNs white non-Hispanic Average age of employed RN is 43.3 CHARACTERISTICS REGISTERED NURSES EMPLOYED IN NURSING - MARCH 1996 & 2000 Source: National Sample Survey of Registered Nurses, Division of Nursing, BHPr, HRSA.

21. DISTRIBUTION OF REGISTERED NURSES BY RACE/ETHNIC BACKGROUNDMARCH 2000 U.S. Population Registered Nurse Population Source: National Sample Survey of Registered Nurses, Division of Nursing, BHPr, HRSA.

22. Trend in Average Age at Graduation from Basic Nursing Education Programs Source: National Sample Survey of Registered Nurses, BHP, DoN, HRSA

23. Minorities are Under-Represented in the Nursing Workforce Racial Composition of US Population and RNs, 2000 Sources: U.S Census Bureau and National Sample Survey of Registered Nurses.

24. ENROLLMENTS IN BASIC NURSING EDUCATION PROGRAMS, 1981 TO 1996 AD BSN DIP Source: National League for Nursing. HRSA Division of Nursing

25. Employed Registered Nurses for Selected States Source: National Sample Survey of Registered Nurses, HRSA, March 2000

26. National Statistics Show High Turnover Among New Nurses Source: The Advisory Board Company, Nursing Executive Center National RN Survey, October 1999

27. Hospital RN Turnover High • Stresses of Job • Physical Demands a Problem for Many Older Nurses • Specialty Units Place Greater Demands on Nurses • Lack of Staff Support • Structure of Jobs

28. Trend in Actual and "Real" Annual Salaries Full-Time Registered Nurses Source: National Sample Survey of Registered Nurses, DoN, BHPr, HRSA, DHHS, Mar 2000

29. A National Nursing Shortage is Projected to Begin in 2007 Requirement Supply Source: Projections by DoN, BHPr, HRSA, DHHS, 2000

30. TRENDS in the SUPPLY AND DEMAND of Allied Health Providers and Pharmacists

31. Demographics of the Allied Health Workforce: Gender

32. Demographics of Allied Health Workforce: Race/ethnicity

33. Demographics of Allied Health Workforce: Age

34. Pharmacists Have the Highest Percent of Unfilled Positions Source: American Hospital Assoc.

35. The Pharmacist Shortage… Its not what you think Pharmacists per 100,000 Population: 1970-2000 Source: Bureau of the Census

36. The Number of Vacancies for Pharmacists Doubled in Last Two Years Unfilled positions in NACDS member drug stores (base of 74,300 FT and 10,900 PT)) FACTORS CONTRIBUTING TO THE SHORTAGE • Increased use of prescription medications • Market factors • Market growth and competition, with expanded hours and new store openings • Time to verify third party coverage, etc • Pharmacy workforce • Women, other professional opportunities.

37. U.S. Physician Supply Adequate Overall, (Maldistribution) Between 2000 and 2015: • The population will grow 13%. • The need for physicians will increase 18% due to medical advances and an aging population. • Constraining need is greater use of non-physician clinicians, e.g. PAs • Physician supply will increase 23%. • Most of the increase will come from foreign trained physicians entering the U.S. for residency training and then stay.

38. The Long Term Care Paraprofessional Workforce

39. Wages for Hospital, Nursing Home and Home Health Aides are Less Than Those of Factory Workers Mean Hourly Wage 1999 Source: GAO-01-750T (2001) and CHWS

40. Paraprofessional Shortages:Worker Perspectives • Low Wages and Benefits • Many Job Alternatives • Poor Working Conditions • Difficult Jobs – Physically/Mentally Demanding • Lack of Career Opportunities: Dead End Jobs • Lack of Recognition or Status • Poor Treatment • Gap Between Training and Real Job Demands

41. Paraprofessional Shortages Employer Perspectives • Too Little Reimbursement • State and Federal Regulations and Oversight • Poorly Prepared and Unmotivated Workers • High Turnover • Low Unemployment Rate • Increasing Patient Acuity • Growth in Total Number of Jobs

42. Hospitals Reporting More Difficulty Recruiting Selected Hospital Workers in 2001 Source: American Hospital Assoc.

43. Employee Dissatisfaction is High • Stressful environment • Too much paperwork – not • enough caring • Loyalty with discipline – co- • workers- patients, not employer • Want more communication and • advancement opportunities

44. Health Professions Jobs Will Grow at Twice the Rate of All Occupations Between 1998-2008 In Thousands 1/ Includes such occupations as nursing aides, home health care aides, dental assistants, medical assistants, pharmacy aides, et al. Source: Dept. of Labor, Bureau of Labor Statistics, Occupational Employment Statistics

45. Few Generation X & Y Choosing Health Care Careers • Low tech • Insecure • Multiple choices for women • Lesser psychic reward • Shift and “dirty” work • Limited role models for minorities/immigrants

46. Workforce Shortage Intervention Approaches 1. Expand Pipeline-Educational Strategies (Supply Side) 2. Improve Retention-Job Related Strategies (Supply Side) 3. Reduce Need and Improve Productivity/Reduce Paperwork (Demand Side)

47. Strategies to Expand Workforce Supply • Grants, capitation funding and/or mandates for educational programs • State funding for training and training initiatives • TANF and other Labor Department funding • Medicaid Funding • State grants • Scholarships, scholarships for service and loan repayment • Marketing health careers/public service announcements • Studies and Reports

48. Strategies toImprove Recruitment & Retention • Increase wages supported by Medicaid reimbursement • Improve benefits i.e. health insurance for workers, portability of benefits within industry • Build career ladders • Grants for innovations and models • Reimbursement reform linking patient needs training/education/skills and pay and reimbursement • Promote health and education sector collaboration

49. Improving Retention (cont’d) • Improve working conditions/job redesign • Grants to support innovations/job redesign • Regulatory changes • Support for family/informal care givers • Management/supervisor training • Mandate minimum staffing ratios (?) • Prohibit mandatory overtime (?)

50. Modify Demand/ Improve Productivity • Regulatory changes on scope of practice/use of workers • Regulatory changes on requirements for health facilities/organizations • Paperwork reduction • Encourage demonstrations and evaluation on job redesign (grants and waivers) • Grants for technology development