The Health Care Workforce St. Paul November 6, 2003

1. The Health Care WorkforceSt. Paul November 6, 2003 Catherine Dower, JD Associate Director - Health Law & Policy UCSF Center for the Health Professions 3333 California Street, Suite 410 San Francisco, CA 94118 cdower@itsa.ucsf.edu

2. Outline • Why health care workforce • Current drivers of change • Supply and demand • Health workforce: the big questions • Responses

3. Why workforce? • 11 million US workers • 6-12% of state workforces • Lead roles in • health care costs • access to care • quality of care and health outcomes/status

4. Drivers of Change7 Health Care Trends Affecting Workforce Demography Consumer Culture Technology Globalization Health Care Environment Disequalibrium

5. MURAL GRAPHIC DYSLEXIA

6. Driver #1 - Demographics Source: U.S. Census Bureau

7. Next generation values Service oriented Anti-institutional Not hierarchical Flexible, welcoming change Diversity Technology New skills Community of work Hospitals Staff is on strike, laid-off, or Angels of Mercy Large, cold, unresponsive institutions Work is stressful, highly structured, dissatisfying Tied to a professional career, not open to change Homogeneous Un-fun Driver #2- Culture

8. Driver #3 - Technology • Biomedical • US investment in basic and applied biomedical leads the world: 85% of intellectual property in biotech • Commercial investment now surpasses public investment • Information • 70-86% of those with Internet access used it to search for health information • Health Care is a Knowledge Based Service Undertaking Sources: Ruzek, JY, et.al, Trends in US Funding of Biomedical Research, San Francisco, CA: UCSF Center for the Health Professions, May 1996. August 2000 Harris Poll; Harris Interactive survey, March 2001

9. Driver #4 – Health Care Environment Stressed care delivery system and institutions • Tighter resources • Lack of direction • Greater demands • Technology • Quality • Job cuts • Uncertainty • Inability to adapt and • change rapidly Variation • Enormous range in definition of quality Capacity • Over/under supply of care providers, hospitals, insurers. Duplication • Substitutable inputs

10. Driver #5 – Changing Consumer • Consumers and Markets • Increased responsibility for individual decision making • More responsibility for cost • Need legislation to protect consumer interests • What is really important: • choice of plan, provider, treatment • information • appeals and direct liability • universal coverage

11. Driver #6: Globalization • Competition • Equity • Legal issues • Information

12. Driver #7: Continued Disequilibrium in Health Care Policy and Market Solutions • Cost– back on the rise • Quality – too many deaths from errors • Access - 15% uninsured and likely to rise

13. In short • Growing demands • Aging workforce; fewer new workers • Maldistribution • Disconnect with next generation • More competition for work • More dissatisfaction & stress at workplace • Inter- and intra-professional angst • Lack of leadership

14. Forecasting demand • Demand-based estimates • current usage … ratios • population growth • Historic workforce growth • Market shortage but misses underserved • Needs-based estimates • Treatment required to meet need • Treatment capacity by profession • Expensive, unrealistic

15. Forecasting Supply • Enrollments/matriculations • Graduates • Licensing data • Vacancies/turnover rates • Workforce surveys • practice patterns • retirement rates

16. Supply and Demand • Medicine • COGME ranges • Specialty mix • “Fleeing” • Nursing • Staffing ratios • Employment vacancies • Recruitment and retention • School enrollment COGME Range: 145-185 MDs/100,000 population

17. Supply and Demand • Allied Health • Historic occupational growth • Limited baseline data • Don’t include all factors • Complementary and Alternative Health • Market demand • Growth of profession (education, licensing)

18. New ways to look at supply and demand • What type and amount of care - across professions - needs to be provided? • How can that care be provided? • E.g.: defining obstetric care

19. Big Questions • Who will provide care? (supply and demand) • Numbers • Profile • What are the leverage points for improving their practice? (competence) • How shall we deal with evolving and emerging professions?

20. Who will provide care?Nursing • Staffing Ratio Costs • $143,836 per hosp • $87 mil all hospitals • opportunity costs • Benefits • improved quality? Source: Coffman et al., CHCF, AHRQ • Gender and race/ethnicity imbalances • State and National nurse staffing shortages • Efforts to address • Private sector • Legislative

21. Who will provide care?Medicine • Stable medical school numbers, graduates • Rising number of residency programs, MDs • Geographic maldistribution • Gender and race/ethnicity imbalances • Primary care/specialist??: specialty shortages • Changing practice patterns • boutiquing • patient base • Successful organizational models

22. Successful practice models? Factors Affecting Incentive Calculation Source: Grumbach et al., UCSF 2002

23. Successful practice models? % Primary Care Physicians Working with Non-Physician Clinicians, CA 2001 Source: Grumbach et al., UCSF 2002

24. Who will provide care?Pharmacy • Changing education & practice patterns • Competitive market; more options • Hospital shortage • Increased demand • Drug costs as % of health costs doubled in 10 yrs • Therapeutic and technological advances • Increased number of prescriptions • Aging population

25. Who will provide care?Dentistry • Geographic maldistribution • 20% of CA Medical Service Study Areas at or below fed standard of 1/5000 pop • Rural shortages • 2/3 of CA shortage areas rural • “Safety Net” shortages • Scope of practice battles between dentists and dental hygienists

26. Who will provide care?Complementary & Alternative Health • Acupuncture, homeopathy, direct-entry midwifery, massage therapy, naturopathy, chiropractic • Uneven public and private recognition across US • Limited workforce and demand data

27. Who will provide care?Allied Health • Mental and behavioral health • Hard to define or count • Medical lab technologists • High vacancies • Radiology technologists • demand skyrocketing • Respiratory care providers • Increased demand; state licensing issues • Home health & long-term care workers

28. The Allied and Auxiliary Health Care Workforce Project • Funded 22 model programs in California to address allied health workforce issues • Co-investigators with the ASCP-BOR on Health Resources Services Administration-funded study of shortage among clinical laboratory science workers • Issue briefs • The Clinical Laboratory Workforce in California • Respiratory Care Practitioners in California • Diagnostic Imaging Professionals in California

29. Major research issues addressed by HRSA study • Demographic characteristics of the clinical laboratory science workers workforce, including level of education • Roles and activities of various types of workers, and potential for substitution of workers and tasks • Key influences on supply and demand • Current and future utilization of workers in primary work settings • Magnitude of any worker shortages and the impact of shortages on the healthcare system • Recommendations to address any imbalances in supply and demand

30. Categories of workers included in HRSA study • Clinical Laboratory Scientists • Medical Laboratory Technicians • Cytotechnologists • Histotechnologists/Histotechnicians • Phlebotomists • Other laboratory personnel, i.e., laboratory assistants

31. Clinical Laboratory Science Workers National Demographics • 79% of laboratory science workers in 2001 were women. • In 2001, 71% of laboratory science workers nationally were white, compared to 74% of the population, and 15% were African-American, compared to 10% of the population. Source: Current Population Survey, Outgoing Rotations 2001, CPS Utilities, Unicon Research Corporation, http://www.unicon.com. These data are for medical technologists and technicians.

32. Average annual salary, US 2002 Source: American Society for Clinical Pathology Board of Registry, Annual Wage and Vacancy Survey, 2002.

33. The workforce shortage among clinical laboratory science workers • In 2002, the national vacancy rate for MT/CLS workers was 7% • In the Far West region, the vacancy rate for MT/CLS workers was 6% • The Wage and Vacancy survey is being conducted again in 2003 Source: American Society for Clinical Pathology Board of Registry, Annual Wage and Vacancy Survey, 2002.

34. MT/CLS programs and graduates, 2001 Education data are for the academic year 2000-2001; US Bureau of Census. States are listed in descending order of population. (CA: 35.1 million, MI: 10.1 million; MN: 4.9 million)

35. Clinical laboratory workers per 100,000 population, 2001 Ratios are calculated using 2001 data from the Bureau of Labor Statistics and the Bureau of the Census.

36. Impact of the shortage on... • Quality of care • Data on testing errors difficult to find & proprietary • Some lab directors: no negative outcomes • Others: test delays, mislabeling, conducting wrong tests • Hospital laboratories • outsourcing; higher costs; economic position in hospital; permanent loss of positions • Laboratory workers • overwork and job burn-out; brain drain to other fields

37. Leverage points for improving health professions practice • Regulation • Education • Workplace • Research • Leadership Not a question of how are we going to make the workforce keep looking the way it did in the 70s or 90s but how are we going to support the evolution of a workforce that will meet future needs

38. Leverage Point: Regulation • Scope of practice acts • Process • Substance • New models • Transition approaches

39. Leverage Point: Education • Support education and training at state and private professional, allied and auxiliary schools • Promote careers in clinical laboratory science • Under-served areas • Scholarships • New models • form: e.g. distance learning • substance: e.g. core competencies/career ladders

40. Leverage Point: Workplace • New practice models • New environment • The case of the safety net institution • Labor and management agreements • “Grow our own” approach Policymakers and foundations should stimulate the development of effective work-redesign strategies. Buerhaus et al., 2002, AHRQ

41. Leverage Point: Research • Data collection • workforce numbers • utilization rates • Rely on data and research for policy • Information dissemination • profession overviews • board actions

42. Leverage Point: Leadership • Leadership and change • Promote professional commitment among workers • What’s dotting your world? • Connecting the dots • Creativity • Getting it done

43. Bright lights • Technology • Emerging professions • New practice models • Changing practice acts • New leaders Imagination is more important than knowledge. Albert Einstein

44. UCSF Center for the Health Professions http://futurehealth.ucsf.edu