Workforce Issues

1. Workforce Issues M6920 October 30, 2001

2. Goals for discussion • Understand how professionals are thought about generally • Understand some major issues about health professionals • Increase sensitivity to licensure issues M6920, Fall, 2001

3. Evolution of work force • Healers exist in every culture • Healing associated with religious system • Enlightenment began Western separation M6920, Fall, 2001

4. Policy questions about the health workforce • What is the role of a professional? • Who is a "provider”? • How do we know they are “safe”? • How many should we have? ????????? M6920, Fall, 2001

5. Professionals or providers? • Workforce is labor market term • Provider is a term of art from payment systems • Independent billing has generally recognized MD, DO, DDS • Others generally seen as either • institutional staffing • secondary practitioners M6920, Fall, 2001

6. Defining professionals • Special body of knowledge • Control over education and qualifications • Limited entry into field • Social recognition M6920, Fall, 2001

7. For all health professionals • Content and volume of education has grown • Cycles of excess and shortage occur • related to employment shifts • related to age groups • related to educational policy • Public expectations have changed M6920, Fall, 2001

8. Supply factors delivery system (wages, benefits) education system (capacity) economic system (unemployment) demographics of profession (age, gender, etc) Demand factors delivery system (technology, acuity) economic system (reimbursement) education system (faculty) population demographics (age, epidemiology) Predicting supply and demand Dumpe et al 1992 Forecasting the Nursing Workforce Nursing Economic$ 16:4 (170-9) M6920, Fall, 2001

9. Geographic distribution • The range of practitioner to population is extremely variable • US: 22.4/10,000 in 1997 • Regional range: • New England 30.4 • West South Central 18.3 M6920, Fall, 2001

10. Health Profession/ Population Ratio* *per 100,000 population Health US, 1999 M6920, Fall, 2001

11. Interprofessional Issues • Socialization • Actual and perceived power • Economic competition M6920, Fall, 2001

12. Physician questions have dominated • Because of the cost of preparation • Because of their primacy in the cost and access equation • Mechanisms have included • Residency support (Medicare) • Enrollment support (HRSA) • Policy on IMG’s M6920, Fall, 2001

13. Physician/population ratio* *Health US, 1999 NE Mid Atlantic South Atlantic E N Central W N Central E S Central Pacific W S Central Mountain M6920, Fall, 2001

14. Physician Supply in NYC Denise Soffel, United Hospital Fund M6920, Fall, 2001

15. Diversity in Medical Students 1990: 65,163 1994: 66,629 M6920, Fall, 2001

16. International medical graduates • 18,000 US graduates for 24,000 residency positions • IMG’s are ~25% of licensed physicians. . . • but 50% of HHC residents and • 75% of 392 residents at Lincoln Hospital (Bronx) M6920, Fall, 2001

17. Ethics of international movement • Beneficence • better care in underserved US areas • Non-malfeasance • Drain from neediest countries • Specialty interests not needed • Autonomy • Social Justice M6920, Fall, 2001

18. Some current questions: • What is the role of the specialist? • What proportion of practitioners should be specialists? • How do we support the academic research machine? ????????? M6920, Fall, 2001

19. Is nursing a profession? • Classics: clergy, law, medicine • Yes: • controls education • limited entry to field • social recognition • personal professional ethic M6920, Fall, 2001

20. Maybe not. . . • social recognition limited • only partial practice independence • most are wage workers • gender perception issues • competition with more prestigious fields M6920, Fall, 2001

21. Distribution of Nurses* *Per 100,000 population Health US, 1999 1,272,900 nurses 1980 M6920, Fall, 2001

22. Types of nurses, 1996* *Health US, 1999 2,161,700 Nurses M6920, Fall, 2001

23. Aging out of nurses Buerhaus, Steiger, Auerhach JAMA 283:22 M6920, Fall, 2001

24. Nurse questions • Shortage focus: hospital staff • Population ratio has grown: 366/100K (1970) to 697/100K (1991) • Responses have included • Changes in length/type of education • International recruitment • Enrollment support (school & student) • Salary changes M6920, Fall, 2001

25. Intensity of nursing • Prior to 1975, number of beds and nurses roughly parallel, with a few less nurses than beds • Since then, number of nurses has risen dramatically while beds decrease M6920, Fall, 2001

26. Impact of hospital closure & shorter stays • up to 300,000 displaced nurses • 1.2 out of 1.9 million nurses work in hospitals • Home health has doubled • Out patient settings have grown 15% M6920, Fall, 2001

27. International graduates • Nursing Relief for Disadvantaged Areas Act of 1999 • 500 nurses may enter for up to 3 years • at least 190 beds • in Health Professions Shortage Area • 35% days Medicare; 28% Medicaid • originally only 14 facilities nationwide qualified M6920, Fall, 2001

28. Some current nursing workforce issues • use of assistive personnel • use of contract personnel • differentiated practice • compression of advanced practice nurses • relationship to vulnerable populations • anticipated shrinkage M6920, Fall, 2001

29. Turnover issues • Stability associated with • older staff • higher income staff • longer tenure • Turnover associated with • tension • limited organizational commitment • supervisor’s behavior M6920, Fall, 2001

30. Nursing Programs in NY • Graduate: 25 • Baccalaureate: 45 • AD: 57 M6920, Fall, 2001

31. Diversity in Nursing Students 1990: 221,170 1994: 270,228 M6920, Fall, 2001

32. Nurses in New York State, 1996 • 96% FEMALE • Average age 47 • in 1983 it was 40 • 36% over 50 • Average age by type of education • BSN 42 • DIPLOMA 52 • AD 44 M6920, Fall, 2001

33. Ethnicity of New York Nurses, 1996 M6920, Fall, 2001

34. Employment settings, NY State RN’s M6920, Fall, 2001

35. CRNA 67,200 CEO 60,000 Midwife 56,700 Dean 54,600 DIR/DP 54,100 Head Nrs 44,500 NP 43,400 CNS 42,100 STAFF 34,900 Faculty 33,800 New York State Mean Salaries (late 1990’s) $$$$$ M6920, Fall, 2001

36. Salaries, cont. • Asian 46,700Black 45,900Puerto Rican 43,800Other Hispanic 43,400Native American 34,400White 33,300 • By region of state • Range 48,900 TO 25,200 M6920, Fall, 2001

37. Public health workforce • Multiple disciplines • Multiple routes of entry • Multiple settings • Overlapping job duties • Confusion among • profession • setting • passion M6920, Fall, 2001

38. Ratio of PH workers to population (by region) *preliminary data

39. Public Health Workers Region IV M6920, Fall, 2001

40. Workers Alabama and Mississippi M6920, Fall, 2001

41. Consumer protection or control of competition? • Limit number licensed? • Require certification? • Extend credentialing process? • Expand disciplinary actions? M6920, Fall, 2001

42. Licensing, certification and credentialing • License is a state issued assurance of minimal competence • Certification is a verification of specialty competence • Credentialing is verification by employing or reimbursing institution M6920, Fall, 2001

43. Professional licensure • Provides validation in community • Affects ability to earn • Once gained, fiercely protected • Very confusing in interdisciplinary practice settings M6920, Fall, 2001

44. Denial Applicant never granted a license Revoke Licensee loses practice privilege Voluntary surrender Licensee agrees to quit practice Suspend License put on hold (time certain or open-ended) Probation Can practice with special conditions Licensing board discipline M6920, Fall, 2001

45. Institutional licensure • Enormous increase in number of licensed or registered groups may rekindle this debate • The employer would be held responsible for hiring people with the right skills for each job • Current credentialing approaches may stimulate M6920, Fall, 2001