HSCI 678 Intro to US Healthcare System

Health Services Workforce

Chapter 8

Tracey Lynn Koehlmoos, PhD, MHA

Roemer Model

• Where are we now?

• Resource Production– Workforce and hospitals– Research and technology

• Where have we been?– Organization of Programs– Management– Economic Support

Health Services Workforce

• Largest Industry in the US

• 11.9 million workers and growing!

• MDs: receive 20% of all personal health expenditures, control 75% of health expenditures

• Nurses, 2 million plus, largest group

• Many more allied professionals

Physicians

• Leadership/entry role in health system• Historical autonomy• Challenges

– Doctor as businessman– Reduced fees– Insurers seek cost containment– Utilization review

• But first…

Medical History 101

• US medical profession followed Brits.

• Apprenticeships, no standardized programs

• 1846—AMA founded, licensing & training– More standardization– More science and research

The Flexner Report

• 1910 by Abraham Flexner and AMA

• Visited 131 US and Canadian med schools

• Found wide variation in all aspects

• Recommended only 31 should stay open

• Johns Hopkins, ideal model

• Closed all but 2 Black medical schools

Med School Today

• About 126 schools for MDs• 12 Osteopathy programs• 4 year program• 17,000 new physicians each year• Rigorous standards• Costly (with great variation)• 50% or more Med School revenue from

provision of services

Graduate Medical Education

• GME, 3-7 year residencies for specialty

• Residents receive stipends

• Each GME costs Fed $70K

• Medicare and Medicaid, largest payers of GME

• No centralized controlling authority

• # Residencies > # Medical Graduates

Who fills the remaining slots?

• International Medical Graduates (IMGs)• Formerly known as FMGs1: to provide foreign MDs with training2: Inexpensive labor for teaching hospitals3: Augment supply of US physicians

IMGs will work in places US physicians will not:Inner City Mental HospitalsPrisons

What do they do?

71%

20%

3% 6%

Office

Hospital

Federal

Other

Supply and Demand

• 813,770 Physicians in US (2000)

• 2/3 Specialists

• Inadequate distribution of providers

• Demand, hard to predict

• Supply, easier to control– Number of Medical School Slots– Number of IMGs based on policy

Specialists v. Generalists

• Generalists: FP’s, Internal Medicine

• 2/3 of physicians are specialists/subspec.

• No emphasis on producing more FPs

• No quick fix

• Managed Care emphasizes the Primary Care Provider (Generalist)—but the idea has not caught on in the US

Physician Summary

• No easy way to predict demand

• There may be an oversupply– True in some areas and specialties– Undersupply in other areas and generalists

• Specialist receive higher reimbursement and more prestige than Generalist

• Generalists are the hub of Managed Care-sort of…

Allied Health Providers

• Laboratory Personnel• PT and OT and RT• Radiology Technicians• Dietitians/Nutritionists• Clinical Psychologists• Speech Pathologist and Audiologists• Medical Records administrators• Medical Social Workers

Midlevel Practitioners

• Physician Assistants (PAs) – Post-Vietnam, medical corpsmen– 20-36 months training– Primary care role good for Managed Care– 55% associated with specialist practices

– Issues of professional territorialism– Licensure restriction

Midlevel Practitioners

• Advance Practice Nurses (APNs)

• Nurse Mid-Wives (4,000)

• Nurse Practitioners (58,500)

• No national standard

• Require physician oversight

• No direct reimbursement to APNs

Nurses

• Largest group in the medical workforce• More than 2 million active nurses• 2/3 work in hospitals• Five levels of nurse education

– CNA—on the job, no certificate– LPN—12 month program (state license)– RN—hospital diploma, AA, BA (state license)– APN—Midwife, ARNP– Clinical specialist—MS (also PhD, ND)

Nursing Shortage

• US-wide, expected to worsen

• Aging nurse workforce (43 average age)

• By 2010, 20% below requirements

• Reality of Nursing:– High entry salary, relatively low increase– Work environment complaints– Cultural change in US

Pharmacists and Dentists

• Pharmacists: 200,000+ – 5-6 years of training– Dependent on MDs to write prescriptions– Increase in elderly patients, increase in

internet and mail order prescriptions

• Dentists: 170,000 – No dependence on physicians!– Have successfully treated decay– Must find other areas to concur including MC

Health Service Administrators

• Highly trained business people and managers (60,000)

• Masters prepared (MHA, MBA, MS)

• Flexibility and leadership– Strategic planning and marketing– Stay current on technology and policies– Accounting and financial management– Clinical management and physical plant

Workforce Summary

• Largest segment of the US workforce

• More women becoming physicians, PAs

• Aging of the nursing workforce

• Racial and Ethnic disparities in all areas