thehidden healthcare workforce - healthforce center...e. gender and race/ethnicity of selected...

the hiddenhealth careworkforce

A Report of the

CALIFORNIA TWENTY-FIRST CENTURY

WORKFORCE PROJECT

July 1999

R E C O G N I Z I N G , U N D E R S TA N D I N G

A N D I M P R O V I N G T H E A L L I E D A N D

A U X I L I A RY W O R K F O R C E

Copyright, 1999 UCSF Center for the Health Professions. All materials subject to this

copyright may be photocopied for the non-commercial purpose of scientific or educational

advancement.

Suggested Citation Style:

Ruzek JY, Bloor LE, Anderson JL, Ngo M and the UCSF Center for the Health Professions.

The Hidden Health Care Workforce: Recognizing, Understanding and Improving the Allied and Auxiliary Workforce.

San Francisco, CA: UCSF Center for the Health Professions. July, 1999.

Funds for this report were provided by the California HealthCare Foundation with

additional support from the Bureau of Health Professions, (HRSA # 5 U76 MB 10001-02).

C A L I F O R N I A T W E N T Y – F I R S T

C E N T U R Y W O R K F O R C E

P R O J E C T S T A F F

The California Twenty-First Century Workforce Project was conducted by

staff at the University of California, San Francisco, Center for the Health

Professions in conjunction with Charles R. Drew University of Medicine and

Sciences, College of Allied Health.

UCSF CENTER FOR THE HEALTH PROFESSIONS STAFF:

Jennifer Anderson, Program Assistant, UCSF Center for the Health Professions

Lindsey Bloor, MS, Research Analyst, UCSF Center for the Health Professions

Mai Ngo, Research Assistant, UCSF Center for the Health Professions

Edward O’Neil, PhD, Co-Director, UCSF Center for the Health Professions

Jennifer Ruzek, Project Director, UCSF Center for the Health Professions

Jonathan Showstack, PhD, MPH, Co-Director, UCSF Center for the Health Professions

CHARLES R. DREW UNIVERSITY, COLLEGE OF ALLIED HEALTH STAFF:

Alicia Dixon, MPH, Laurel Consulting Group

James Kyle, MD, Charles R. Drew University

Paul Simms, MPH, Charles R. Drew University, College of Allied Health

C A L I F O R N I A T W E N T Y- F I R S T

C E N T U R Y W O R K F O R C E

P R O J E C T A D V I S O R Y C O M M I T T E E

Mike Kassis, MPA

Deputy DirectorHealthcare Information DivisionOffice of Statewide Health Planningand Development

James Kelly, PhD

DeanCollege of Health and Human ServicesCalifornia State University, Los Angeles

BabaTunde Oyefeso, BS, ART

Recent Graduate (1995)Health Information ProgramCharles R. Drew University

Paul Pursell

Director, Physical Rehabilitation ServicesSt. Joseph Hospital

Norma Resneder, MS

Director, Human ResourcesWestern DivisionTenet Health System

Ernie Roy, EdD

PrincipalKing Drew Medical Magnet High School

Joan Steiner-Adler, MT, EdD

Program DirectorSchool of Medical Technology Eisenhower Medical Center

Nancy Barrett, LVN

Assistant Division Director, Long-TermCare FacilitiesSEIU Local 250

Beverly Campbell

ManagerSchool-to-Career Unit Department of Education

Carolyn Drake, RN, EdD

Associate Dean, Instruction Health Sciences Fresno City College

Barbara Gallardo, BS, BAM

Regional Director, Clinical OperationsPacific RegionVencor, Inc.

Barbara Hanna, RN, PHN

President and CEOHome Health Care Management, Inc.

Judi Hansen, MBADirector, Workforce, Diversity andTransition Planning Kaiser Permanente

Joyce Hopp, PhD, MPH, RN

DeanSchool of Allied Health ProfessionsLoma Linda University

Craig Howard, MPH, MA

Senior Program DirectorJames Irvine Foundation

EXECUTIVE SUMMARY .......... i

SECTION I : INTRODUCTION .......... 1An Eroding Professional Landscape .......... 1Who Are Allied and Auxiliary Workers? .......... 3Methodology and Scope of the Project’s Work .......... 4Structure of the Report .......... 5Seven Core Themes .......... 5Recommendations for Action .......... 9

SECTION I I : SOCIAL, POLITICAL, TECHNOLOGICAL AND ECONOMIC

TRENDS THAT AFFECT HEALTH CARE .......... 12

Health Care in California: Harbinger for a Nation .......... 13

A. Consolidation in a Managed Care System .......... 14

1. Stages of Managed Care Penetration by California Region .......... 15

2. Consolidation of Hospitals and Health Plans in California .......... 18

3. Implications for the Workforce .......... 19

B. Integration and a New Worker .......... 20

C. A Shifting Demographic: Older and More Diverse .......... 22

1. An Aging Society .......... 22

2. Age and the Workforce .......... 23

3. Ethnic Diversity .......... 24


D. Changes in Regulatory Structures .......... 28

1. Regulation of Professions and Occupations .......... 28

2. Examples of Uncoordinated Regulation .......... 31


E. Consumer Choice, Competition and Accountability .......... 33

F. Technological Advancement: Clinical and Information .......... 35

G. The Indigent, Uninsured and Welfare Populations .......... 37

1. Widening Income Gap .......... 38

2. The Uninsured .......... 39

3. Welfare Reform .......... 40


T A B L E

O F C O N T E N T S

SECTION I I I : CARE DELIVERY SETTINGS .......... 46

A. Hospital Care .......... 46

B. Ambulatory Care .......... 52

C. Home Health Care .......... 56

D. Long-Term Care .......... 65

E. Clinical Laboratories .......... 71

SECTION IV: CHARACTERISTICS/DEMOGRAPHICS OF ALLIED AND AUXILIARY

HEALTH CARE WORKERS .......... 75

A. Size, Composition and Distribution .......... 75

B. Location of Practice .......... 79

C. Gender and Race/Ethnicity .......... 80

D. Wage Rates .......... 84

E. Union Affiliation .......... 92

SECTION V: CHALLENGES FOR THE ALLIED AND AUXILIARY

HEALTH CARE WORKFORCE .......... 96

A. Trends in the Allied and Auxiliary Workforce Environment .......... 97

1. Transfer of Work .......... 98

2. Multiskilling .......... 99

3. Changing Demands in Education and Training .......... 102

4. Outsourcing, Subcontracting and Temporary Workers .......... 116

5. Changing Career Expectations .......... 121

6. Pressure on Benefits and Wages .......... 124

7. The Changing Role of Unions .......... 128

B. The Worker’s Perspective: Focus Group Results .......... 133

1. Targets for Change .......... 136

2. Increased Workload .......... 136

3. Need for Empowerment .......... 136

4. Pay Versus Other Priorities .......... 137

SECTION VI : SOCIAL, POLITICAL, TECHNOLOGICAL AND ECONOMIC TRENDS

AFFECTING EDUCATION .......... 141

A. Changing Student Populations .......... 141

1. K-12 Student Population .......... 141

2. Students in Postsecondary Education .......... 142

3. Implications .......... 142

B. Advances in Information Technology .......... 143

C. Movement to a Knowledge-Based, Service Economy .......... 144

1. An Increasing Emphasis on Markets, Consumer Accountability and Competition inEducation .......... 144

2. The Increasing Economic Value of a College Degree .......... 145

D. Shift in Public Financial Support For Education .......... 147

1. Failing Financial Support from State Governments for Higher Education .......... 147

2. Changing Policies for Tuition and Financial Aid in Higher Education .......... 148

E. New Employability Skills .......... 149

SECTION VII : PROFILE OF CALIFORNIA’S EDUCATIONAL SYSTEM .......... 154

A. K-12 Educational System in California .......... 154

1. Demographics .......... 154

a. Enrollment and Projections .......... 154

b. Graduation, Attrition and Dropout Rates .......... 155

c. Low Educational Expenditures for K-12 .......... 155

2. Complex Challenges for K-12 Reform .......... 155

a. Inadequacy of Math and Science Preparation .......... 156

b. Class Size Reduction and Teacher Supply and Demand .......... 157

B. Postsecondary Educational System in California .......... 159

1. Demographics .......... 159

a. Definition of Postsecondary Education .......... 159

b. Student Enrollment .......... 160

c. Number, Type, Size and Variety of Postsecondary Institutions in California .......... 160

d. Proprietary Education .......... 162

2. Issues for Postsecondary Education .......... 163

a. Remedial Education .......... 163

b. Lack of Appropriate Faculty and Teacher Development .......... 165

c. California’s Approach to “Segmentation” and the Effect onStudent Transfer .......... 166

d. Growth of Proprietary Education .......... 167

e. Barriers Posed by Accreditation .......... 169

SECTION VII I : HEALTH-SPECIFIC EDUCATION AND TRAINING PROGRAMS .......... 175

A. Description of Health-Specific Education Pathways .......... 175

1. The School-to-Work/Career Process .......... 175

2. Health Careers Education Program .......... 178

3. Health Careers Education Pathways .......... 179

a. California Partnership Academies .......... 180

b. Regional Occupational Centers and Programs .......... 180

4. Health Occupations Students of America (HOSA) .......... 181

B. Description of Allied Health Programs at the Postsecondary Level .......... 182

1. Current Allied Health Programs .......... 182

2. Survey of Programs .......... 183

3. Student Demographics .......... 184

4. Changes in Programs .......... 185

C. Description of Auxiliary Training Programs .......... 188

1. Profile, Number and Distribution of Programs .......... 188

a. Home Health Aide* .......... 188

b. Nurse Aide* .......... 190

c. Certified Nursing Assistant* .......... 192

2. Job Training Partnership Act Programs .......... 195

3. Emergence of Community-Based Training Programs .......... 199

D. On-the-Job Training .......... 202

1. Changing Employer Needs .......... 202

2. Scope and Variety of On-the-Job Training .......... 203

3. Location of Training .......... 204

4. Transferability and Documentation of Skills Learned On the Job .......... 205

5. Implications and Signals to Educators .......... 205

SECTION IX: CONCLUSIONS/DEVELOPING POLICIES FOR SUSTAINABLE CHANGE .......... 207

APPENDICES .......... 217

A. Methods for Care Delivery Research .......... 217

B. Glossary of Terms .......... 224

C. California County Consortiums .......... 227

D. Distribution of Selected Allied Health Care Occupations and Professions byCalifornia County Consortiums .......... 229

E. Gender and Race/Ethnicity of Selected Allied Health Care Occupations andProfessions .......... 234

F. Wages for Selected Allied and Auxilliary Health Care Occupations and Professions byCalifornia Counties .......... 241

CITATIONS .......... 249

*Profiles define and describe the skills and duties for three auxiliary health care occupations.

Number Exhibit Title

SECTION I I : SOCIAL, POLITICAL, TECHNOLOGICAL AND ECONOMIC TRENDS

THAT AFFECT HEALTH CARE

Exhibit 1: Hospital Consolidation in California - Number of Facilities andPercent of California Total .......... 19

Exhibit 2: Percent Increase of Elderly Population, United States vs. California, 1990 to 1996 .......... 22

Exhibit 3: Projected Percent Increase of Total Elderly Population(Defined as 65 years of age and older) .......... 22

Exhibit 4: Projected Change in Number of Workers in United States Labor Force by Age Group,1996 to 2006 .......... 23

Exhibit 5: Ethnic/Racial Composition of United States Population, 1990 to 1998 .......... 24

Exhibit 6: Ethnic/Racial Composition of California Population, 1990 to 1996 .......... 25

Exhibit 7: Percent of Uninsured Population, United States vs. California, 1996 .......... 39

SECTION I I I : CARE DELIVERY SETTINGS

Exhibit 8: Hospital (Short-term General) Beds in California per 1,000 Residentsby County, 1997-98 .......... 48

Exhibit 9: Profit Status of Hospitals in California, 1996-97 .......... 49

Exhibit 10: Distribution of California Medical Groups by Group Size, 1996 .......... 54

Exhibit 11: Profit Status of Home Health Agencies in California, 1995 .......... 57

Exhibit 12: Medicare Home Health Visits and Incurred Expenditures .......... 58

Exhibit 13: Statewide Trends in Home Health Agency Utilization, 1990 to 1995 .......... 59

Exhibit 14: Percent of Patient Population Served by Home Health Care Agencies inCalifornia by Age Group, 1995 .......... 60

Exhibit 15: Percent of Patient Visits Made by Particular Staff Members inHome Health Agencies in California, 1995 .......... 63

Exhibit 16: Home Health Care Employment by Selected Occupations, 1990 and 1993 .......... 64

Exhibit 17: Ten Most Frequently Offered Specialty Home-Care Services by Number of Sites, 1997 .......... 65

Exhibit 18: California Profile of Long-Term Care Facilities, 1995 .......... 66

Exhibit 19: Skilled Nursing Facility Beds in California per 1,000 Residents by County, 1997-98 .......... 67

Exhibit 20: Profit Status of Nursing Facilities in California, 1995 .......... 66

SECTION IV: CHARACTERISTICS/DEMOGRAPHICS OF ALLIED AND

AUXILIARY HEALTH CARE WORKERS

Exhibit 21: Health Care Employment as a Percentage of Total County Employment, 1995 .......... 76

Exhibit 22: Counties With Highest Numbers of Employment in Health Care, 1995 .......... 76

Exhibit 23: Basic Composition of California’s Health Care Workforce by Personnel Type, 1995 .......... 77

Exhibit 24: Detailed Composition of California’s Health Care Workforce by Personnel Type, 1995 .......... 77

Exhibit 25: Composition of Health Care Providers in California, 1995 .......... 77

L I S T O F E X H I B I T S

Exhibit 26: Distribution of Maids and Housekeeping Cleaners in Health Care and inNon-Health Care Sectors, 1995 .......... 78

Exhibit 27: Distribution of Cooks in Health Care and in Non-Health Care Sectors, 1995 .......... 78

Exhibit 28: Distribution of California’s Health Care Workforce by Setting, 1995 .......... 80

Exhibit 29: Distribution of California’s Allied Heath Care Workforce by Setting, 1995 .......... 80

Exhibit 30: Racial/Ethnic Composition of Personnel Employed inCalifornia Medical Offices, 1996 .......... 82

Exhibit 31: Racial/Ethnic Composition of Personnel Employed inCalifornia Nursing Facilities, 1996 .......... 82

Exhibit 32: Racial/Ethnic Composition of Personnel Employed inCalifornia Hospitals, 1996 .......... 82

Exhibit 33: Racial/Ethnic Composition of Personnel Employed inCalifornia Health Facilities, 1996 .......... 82

Exhibit 34: Racial/Ethnic Composition of California Population, 1996 .......... 83

Exhibit 35: Female Representation in Four Health Care Settings in California, 1996 .......... 83

Exhibit 36: Racial/Ethnic Composition of Professionals and Non-Professionals in California, 1996 .......... 84

Exhibit 37: California Mean Wages for Selected Health Care Occupations and Professions, 1996 .......... 85

Exhibit 38: California Average Hourly Wages for Auxiliary Occupations, 1996 .......... 86

Exhibit 39: Percent Change in Median Weekly Earnings (Unadjusted), 1989 to 1996 .......... 87

Exhibit 40: National Median Weekly Earnings (Adjusted for Inflation), for SelectedTherapeutic and Teaching Occupations, 1989 to 1996 .......... 88

Exhibit 41: National Median Weekly Earnings (Adjusted for Inflation) for SelectedTechnologist/Technician Occupations, 1989 to 1996 .......... 88

Exhibit 42: National Median Weekly Earnings (Adjusted for Inflation) for Selected ServiceRelated Occupations, 1989 to 1996 .......... 88

Exhibit 43: Hourly Wages (Adjusted for Inflation) for California HospitalOccupational Categories, 1993-94 to 1996-97 .......... 89

Exhibit 44: Wage Rates for Selected Occupations in Health Care vs. All Private Industries, 1998 .......... 90

Exhibit 45: Wage Rates for Selected Occupations in Health Care, Personal Services andRetail Trade Industries, 1998 .......... 91

Exhibit 46: Wage Rates for Selected Occupations in Health Care, Education, Sales/Finance andComputer/Technology Industries by Educational Attainment, 1998 .......... 91

Exhibit 47: Pharmacists, Pharmacy Technicians and Pharmacy Aides, California Median Wageand Estimated Number Employed, 1996 .......... 92

Exhibit 48: Occupational Therapists and Occupational Therapy Assistants and Aides, CaliforniaMedian Hourly Wage and Estimated Number Employed, 1996 .......... 92

Exhibit 49: Medical Laboratory Technologists and Technicians, California Median Hourly Wage andEstimated Number Employed, 1996 .......... 93

Exhibit 50: National Union Representation by Health Care Setting, 1998 .......... 93

Exhibit 51: National Union Representation of Selected Health Care Occupations, 1998 .......... 94

Exhibit 52: Percent Union Representation by Industry, 1983 to 1998 .......... 95

SECTION V: CHALLENGES FOR THE ALLIED AND AUXILIARY HEALTH CARE WORKFORCE

Exhibit 53: Multiskilling Combinations .......... 103

Exhibit 54: Health Care Core and Occupational Clusters .......... 104

Exhibit 55: National Health Care Skill Standards .......... 105

Exhibit 56: Skills Needed in Hospitals across Personnel Categories .......... 109-110

Exhibit 57: Skills Needed in Skilled Nursing Facilities across Personnel Categories .......... 111

Exhibit 58: Skills Needed in Home Health Agencies across Personnel Categories .......... 112

Exhibit 59: Skills Needed in Clinical Laboratories across Personnel Categories .......... 112

Exhibit 60: Average Wages for Select Allied and Auxiliary Personnel in CaliforniaLong-Term Care Facilities, 1996 .......... 126

Exhibit 61: Employee Average Monthly Cost and Percent of Total Cost for Health Care Workers inLong-Term Care Facilities in California, 1996 .......... 127

Exhibit 62: Average Monthly Costs for Dental and Vision Care for Employees of Long-Term CareFacilities in California, 1996 .......... 127

Exhibit 63: Rating of Job Features .......... 137

Exhibit 64: Participant Responses to Workplace Concepts .......... 139

SECTION VI : SOCIAL, POLITICAL, TECHNOLOGICAL AND ECONOMIC TRENDS

THAT AFFECT EDUCATION

Exhibit 65: Characteristics of California Higher Education Students, Fall 1997 .......... 142

Exhibit 66: Median Annual Income of Males Ages 25-34, 1994 .......... 146

Exhibit 67: High School Seniors’ vs. Employers’ Perceptions aboutBeing Very Well Prepared for Work .......... 151

SECTION VII : PROFILE OF CALIFORNIA’S EDUCATION SYSTEM

Exhibit 68: Credit Enrollment in California Postsecondary Institutions, Fall 1997 .......... 160

Exhibit 69: The Campuses and Economic Size of Postsecondary Education in California, 1997 .......... 161

Exhibit 70: List of Accrediting Bodies for Allied Health .......... 171-172

SECTION VII I : HEALTH SPECIFIC EDUCATION AND TRAINING PROGRAMS

Exhibit 71: Regional Occupational Centers and Regional Occupational Programs, Secondary(High School) and Adult Enrollment by Program, 1996-97 .......... 181

Exhibit 72: Degrees Awarded in “Health Professions and Related Sciences” Among CaliforniaFour-Year Institutions, Selected Years Between 1987-88 and 1996-97 .......... 183

Exhibit 73: Comparison of California Allied Health Student Demographics:1996 Population Estimates versus All, Advanced, Moderate and Basic Level ProgramsResponding to Race/Ethnicity Survey Question .......... 185

Allied and auxiliary health care workers make up over 60 percent of the nation’s 10.5

million-person health care workforce. These workers, ranging from physical therapists

and technicians at the allied level to unlicensed assistive personnel and custodial workers

at the auxiliary level, play critical support roles in the health care system. Any significant

reform in the way health care is delivered will mean a change in how these individuals

are trained and utilized. Yet, employers and researchers have often overlooked their

contributions and their concerns.

The California Twenty-First Century Workforce Project represents a comprehensive

examination of the supply and distribution of allied and auxiliary health care workers, the

educational system that readies these workers for careers, and the pressures that California’s

dynamic managed care environment exerts on them. With funding from the California

HealthCare Foundation, the Workforce Project was conducted by the University of

California San Francisco, Center for the Health Professions in conjunction with Charles R.

Drew University of Medicine and Sciences, College of Allied Health. The Project’s

examination consisted of reviewing pertinent literature, collecting demographic data on

California’s health care workforce, and conducting qualitative surveys, interviews and focus

groups throughout the state. The study finds an allied and auxiliary workforce suffering

from high rates of turnover, ill-defined expectations, low pay and inadequate training.

Three contributing factors to these issues are identified:

Care delivery organizations are struggling to survive in California’s competitive health care

market as pressures to control costs, satisfy consumers, and improve quality have

transformed the way in which care must now be delivered.

Workers are being asked to become more flexible, more tolerant of uncertainty and more

capable team members. The era when workers remained with one institution through an

entire career is over.

Educators are having difficulties preparing future workers with appropriate skills for their

new roles. They are confronted with numerous challenges at a time when the skill sets of

young people graduating from California high schools and colleges are eroding.

i

the h idden health care workforce

C A L I F O R N I A T W E N T Y- F I R S T C E N T U R Y W O R K F O R C E P R O J E C T

E X E C U T I V E S U M M A R Y

t he h idden hea lth ca re workf orce

ii Although the future of allied and auxiliary workers depends on these three

constituencies, care delivery organizations, workers, and educators have set policies in

isolation from one another. The overriding challenge of the next decade will be to build

partnerships among these constituencies that allow institutions to create new approaches

to health care that contain cost, increase quality and improve consumer satisfaction, while

integrating the allied and auxiliary workforces into those new approaches, by cultivating

their skills, creativity, loyalty and motivation.

The Workforce Project has identified seven themes that permeate the challenge of

reinventing the allied and auxiliary workforce. The themes and the related findings are:

1. New Divisions of Labor

To meet immediate demands of reducing costs and increasing productivity, employers

are transferring work to the least costly provider and creating a more flexible,

multifunctional workforce. These trends can be challenging and disruptive to workers,

and their efficacy has not always been established with outcomes data.

2. Lower Pay With More Responsibility

Limiting benefits and wages represent key vehicles for cost reduction. For some of the most

highly skilled professions, wage rates have kept pace or sometimes exceeded rates of

inflation. Yet, for other allied and auxiliary occupations, particularly at the entry level,

wages have remained flat or decreased.

3. The Struggle to Attract and Retain A Quality Workforce

Employers struggle to attract, retain and promote a skilled workforce. At all levels,

employers have difficulty attracting workers with critical thinking, communication and

computer skills as well as a strong work ethic. While turnover rates are problematic and

many current and future labor shortages were identified, few leaders in human

resources departments are addressing these challenges with long-term solutions.

4. The Need to Tie Human Resources to a Quality Strategy

At a time when many health care delivery institutions and systems are recognizing the

need to compete on the basis of quality, few organizations offer a human resources

U C S F C E N T E R F O R T H E H E A LT H P R O F E S S I O N S

initiative tied to a quality strategy. This requires investments in all members of the

health care organization — not just the highest paid managers or clinicians — and an

understanding of the importance of a committed workforce to delivering high quality care.

5. Regulatory and Oversight Inconsistency

Regulatory standards that guide the practice of allied and auxiliary workers are

disconnected from the realities of the modern care delivery system. Out-of-date

accreditation and licensure standards that do not reflect modern care delivery nor quality

improvement principles have gone unchallenged.

6. A Widening Gap Between Education and the Needs of Industry

The educational system has not offered a product that meets the needs of the care

delivery system or students seeking careers in allied or auxiliary positions. Employers

cite increasing skill deficits in their workforce, including technical and computer skills,

critical thinking, communication, management, delegation, supervision skills and an

orientation to a systems perspective. Recent graduates of allied health programs cite

similar skill deficits in their preparation for modern health care careers.

7. The Changing Nature of Work and Career Advancement

The fundamental meaning of ‘work’ is changing in the post-industrial, service-

oriented economy. At all levels — individual, organization and market — change

appears to be a constant characteristic, and workers increasingly find that the skills

with which they were formally trained are becoming obsolete.

RECOMMENDATIONS

The challenges that the Project highlights are caused in large part because of the divisions between

care delivery, education, labor unions and the workforce itself. The following recommendations

propose the use of partnerships among these sectors to address specific issues as well as the

collection of data to evaluate the outcomes of these partnerships and recommended actions.

Recommendation 1. Define skill requirements that are aligned with care delivery

standards, reflecting both general employment skills and core clinical and technical

iii




iv competencies, for the allied and auxiliary health care workforce. Require health

training programs to meet these skill requirements and standards as part of their

accountability to students and the public.

Recommendation 2. Expand training and awareness to better prepare the workforce to

deliver health care to an increasingly multicultural society. First, define and develop

competencies for delivering culturally sensitive care for all allied and auxiliary workers.

Second, actively support hiring and training a more diverse workforce.

Recommendation 3. Create new types of health services work environments in which

care delivery organizations are committed to high quality, flexibility, service

orientation and cultural diversity. Improve conditions of employment in order to

sustain the new types of work environments.

Recommendation 4. Position the allied and auxiliary workforce in health care

delivery’s strategic process of improving the quality of patient care.

Recommendation 5. Build new participatory structures that involve labor, education,

and the allied and auxiliary workforce in change and quality improvement processes.

Recommendation 6. Encourage allied and auxiliary health care workers to take

advantage of career enhancement opportunities to develop and expand their skills in

the rapidly changing health care environment.

Recommendation 7. Improve regulation of professions, occupations and health care

facilities in order to align the training and use of allied and auxiliary workers with the

needs of care delivery. Allow allied and auxiliary workers to practice effectively and to

their full capabilities.


When asked to describe “health care workers”, doctors and nurses often come to mind first.

The legions of supporting staff — the therapists, technicians, clerks, aides, assistants, and

others who keep health care institutions running efficiently — tend to fade into the

background, their role and importance not entirely clear. They are not professions that

typically capture the imaginations of young people, spark the curiosity of health services

researchers, nor get the lead roles on television medical dramas.

And yet these allied and auxiliary health care providers constitute at least 60 percent of the

nation’s 10.5 million health care workers. They are responsible for making the apparatus of

the health care system work when and where physicians and nurses call on it. They generate

a significant amount of the personal contact patients have with the health care system. They

must have a sensitivity to and understanding of the clinical processes that support quality

care, positive health outcomes and profitable operation. Further, any significant reform in

the way in which health care is delivered and received by the public will mean a change in

how these individuals work.

The California Twenty-First Century Workforce Project was conceived to remedy neglect

by researchers, policy makers and institutional leaders of this vital component of the health

care system. Funded by the California HealthCare Foundation, the Project was launched in

the fall of 1997 as an initiative of the University of California, San Francisco, Center for the

Health Professions in conjunction with the Charles R. Drew University of Medicine and

Sciences, College of Allied Health. Its mission was to develop a comprehensive study of the

allied and auxiliary workforce in California — its size, skills, scope of responsibility,

training, regulation, and the challenges it faces in the changing health care environment.

AN ERODING PROFESSIONAL LANDSCAPE

Through a comprehensive literature review, numerous surveys of workers and health care

leaders (see Appendix A for the Project’s methodology), and an examination of broad societal

trends affecting the training and deployment of human resources in health care, the

Workforce Project concludes that allied and auxiliary health workers are overlooked by the

1



I N T R O D UC T I O NS E C T I O N I


2 institutions that need them most. Ultimately, institutions are making vital positions less

attractive to young people weighing careers in health care against other fields. Many of the

jobs examined in this study are more demanding than they once were, promising less pay,

fewer opportunities for advancement, and more uncertainty than before the managed care

era. There is a distinct danger that continuing to neglect the allied and auxiliary health

professions will compromise patient care in the future.

Ultimately, the Project found that the future of allied and auxiliary work will be

determined by the interactions of three trends:

• The further development of managed care and system-based health;

• The redefinition of work in the modern economy; and

• The evolution of California’s educational system.

Care delivery organizations are struggling to survive in California as pressures to control costs,

satisfy consumers, and improve quality have transformed the way in which care must now be

delivered. Efficiency of delivery and the bottom line have never been so important, and the

fiscal pressure that has already caused numerous bankruptcies among provider organizations

shows no signs of abating soon.

Workers are being asked to become more flexible, more tolerant of uncertainty and more

capable team members. The era when workers remained with one institution through an

entire career is over. Many are choosing to become independent contractors, content to

self-finance their insurance and benefits. Others are resisting the change, neglecting their

skills, and finding few options if they are laid off as the result of economic dislocation.

Educators are having difficulties preparing future workers with appropriate skills for their

new roles. They are confronted with numerous challenges at a time when the skill sets of

young people graduating from California high schools and colleges are eroding. Remedial

education is on the rise, as are proprietary alternatives to under-funded public education.

Increasing immigration presents language and cultural barriers to rapid, broad-based

improvement in student skills and knowledge.

While the study concludes that the institutional fates of health care delivery

organizations, educational programs, labor unions and professional associations are

linked, their strategic orientation, operating structures and polices remain isolated from

one another. Although these groups have traditionally operated in a fragmented


environment, the overriding challenge of the next decade will be to build partnership

structures that allow institutions to create new approaches to health care that contain cost,

increase quality and improve consumer satisfaction. A more specific challenge will be to

integrate the allied and auxiliary workforces into those new approaches, cultivating their

skills, creativity, loyalty and motivation.

WHO ARE ALLIED AND AUXILIARY HEALTH CARE WORKERS?

Over 200 different occupations and professions fall under the broad definition of allied

health, including personnel who provide therapeutic, diagnostic, informational or

environmental services in health care delivery settings, with direct or indirect care and

support services to patients. Examples of allied health professions include physical

therapists, physical therapy assistants, medical laboratory personnel, medical record

technicians, medical assistants, and radiology technologists and technicians. Some of these

providers may be licensed, registered or certified. Allied health providers do not include

physicians, pharmacists, optometrists, physician assistants nor nurses (nurse practitioners,

registered nurses or licensed vocational nurses). These and other terms used throughout

this report are defined in Appendix B.

The auxiliary workforce is a less well-defined group and mostly encompasses hospital-

based support and service occupations. Typically, these workers are not licensed, registered

nor certified. Examples of such occupations are unlicensed assistive personnel (e.g., nurse

aides and assistants that may be termed care partners or service partners), hospital janitors,

dietary workers or laundry personnel.

The Project collected data on the supply of a broad array of allied and auxiliary

professions, which are presented in Appendices C, D and E of the report. However, the detailed

analysis focused on a fewer number of representative occupations and professions. The

study was not limited to these specific occupations and professions, but rather used them as

sentinels to highlight the general skill and competency requirements that can be generalized

to other allied and auxiliary health care professions.

These sentinel professions were selected on the basis of preliminary interviews with leaders

in the care delivery system and based on factors such as predicted future growth, potential

for displacement, representation among core skill sets (diagnostic, therapeutic,

information systems and environmental), size of the profession and representation among

3




4 different educational pathways (post-high school, six-month certificate programs, one to

two-year programs at community colleges, four-year degree programs, etc.). Two additional

factors were considered for the auxiliary occupations: opportunity for advancement within

the health professions and occupations with wages at or near the poverty level. While the

Project focused on allied and auxiliary health care workers, out of necessity, it also assessed

the changes occurring in other professions, such as nursing, that have an impact on the

allied and auxiliary workforce.

METHODOLOGY AND SCOPE OF THE PROJECT’S WORK

An advisory committee was convened in 1998 to assist in ensuring that the issues relating to

the Project were fully understood and developed, and to guide the development of

appropriate policy recommendations for the diverse regions and communities in the state

of California. Committee members included representatives from a variety of settings:

hospital, home health, long-term care, clinical laboratory, education and health care union

settings, as well as representation from state government agencies and a recent allied health

student graduate.

Primary data were collected from structured surveys, interviews, and focus groups conducted

with representatives from health care delivery settings, educational institutions, and the

allied and auxiliary health care workforce. These findings were supplemented with the

available supply of the workforce described in secondary data. Researchers examined issues

and trends across a spectrum of health care settings, including hospitals, medical groups,

home health agencies, long-term care facilities and clinical labs. Both qualitative and

quantitative data were collected on the supply of and demand for allied and auxiliary workers,

and on the skills and competencies that these occupations and professions will need in the

future. For a detailed description of the Project’s qualitative methodology, see Appendix A.

While the changes occurring in health care are complex, they are also accompanied by

broader shifts in society that affect the work, training, and availability of allied and auxiliary

workers. The Project also examined the challenges that the educational system faces in

producing a highly skilled workforce that meets the needs of the health care sector. Finally

the Project generated a set of policy recommendations, summarized in the Introduction and

described in detail in Section IX of the report. They address challenges in the areas of care

delivery, education, regulation, labor and community involvement.


STRUCTURE OF THE REPORT

This report is organized to describe and synthesize findings about the health care system

as a whole, the nature of the allied and auxiliary workforce and the educational system

in California.

Sections II and III document the changes occurring in California’s rapidly evolving health

care system. They describe how cost pressures, consumerism, demographics, technology, and

regulatory structures are conspiring to radically change the nature of work in health care.

Section IV describes what the Project learned about the size, scope, and structure of the

allied and auxiliary workforces, with special attention paid to its racial and ethnic mix and

the distribution of workers across the state. Section V describes seven challenges and trends

affecting the nature of allied and auxiliary work, concluding with findings from a survey of

workers. In many ways, these represent the core findings of the Project.

Because education and training are critical contributors to the quality of the allied and

auxiliary workforce, Section VI examines the social, political, technological and economic

trends affecting California’s educational system, at both the K-12 and higher education

levels. Next, Section VII provides an overview of this system of education. Section VIII

elaborates on those findings by documenting the state of health education pathways, allied

health programs and auxiliary training programs.

Finally, the report concludes with a set of recommendations for the recognition and

improvement of the allied and auxiliary workforce and work environment. Broad

recommendations are broken down to the specific contributions that need to come from

providers, educational systems, organized labor and the workers themselves. The Project

finds that efforts need to be made to create new structures and financing mechanisms and

that institutions need to change the ways that workers contribute value to the health care

production process. To provide cost-effective health care, providers must realign work

settings and worker skills, while redefining allied and auxiliary workers.

SEVEN CORE THEMES

The findings of the Workforce Project are shaped by a number of interacting themes, some

of which were explored specifically and others that emerged from the findings. These seven

core themes offer the best overview of the Project’s findings regarding the allied and

auxiliary workforce’s changing environment and emergent challenges.

5




6 1. New Divisions of Labor

The care delivery system is repositioning the allied and auxiliary workforce in several

ways to meet immediate demands of reducing costs and increasing productivity. The two

most visible efforts are the transfer of work to the least costly provider and the creation

of a more flexible, multifunctional workforce. As a result, providers must perform at

their maximum skill capacity while transferring less complicated duties to lesser-trained

and lower paid providers. The practice of training workers in multiple functional areas

also creates flexibility within the workforce, reducing costs and limiting the number of

providers that come in contact with patients. Although implemented at varying levels

and degrees, multiskilling and the shift of work represent first steps in cost reduction

efforts. Both steps have been met with tremendous resistance from the health care

workforce who have had to change and increase their workload significantly.

Furthermore, the efficacy of efforts to reposition the allied and auxiliary workforce has

not been substantiated, positively or negatively, with outcomes data.

2. Lower Pay With More Responsibility

Limiting benefits and wages represent key vehicles for cost reduction in health care.

Benefits have historically been generous at all levels of employment in health care, but

as cost pressures mount, health care employers may attempt to contain or reduce these

benefits. For some of the most highly skilled professions, wage rates have kept pace or

sometimes exceeded rates of inflation. Yet, for other allied and auxiliary occupations,

wages have remained flat or even decreased over time. Also, many entry-level wage rates,

ranging from $6 to $10 per hour, are comparable to other service sector entry-level

jobs that require far less skill preparation and responsibility. Further, although the

responsibilities of entry-level positions have often increased dramatically, wage rates

have changed very little.

3. The Struggle to Attract and Retain a Quality Workforce

As it reduces costs, the care delivery system struggles to attract, retain and promote a workforce

with the skills required to function in the rapidly changing environment. In general, the pool

of workers for the lowest skilled, entry-level positions is larger but less qualified than the labor

pool for highly skilled, licensed providers. Yet at all levels, employers have difficulty attracting


workers with critical thinking, communication and computer skills as well as a strong work

ethic. Additionally, related work experience was cited as the most common skill deficit in

hiring. The Project’s survey also found that few workers advance from entry-level positions

despite the presence of tuition reimbursement programs in most hospitals.

While turnover rates were often qualitatively described as problematic and many

current and future labor shortages were identified, few leaders in human resources

departments are addressing these challenges with long-term solutions. Many were

simply mired in the day-to-day work of staying afloat in a highly competitive

marketplace. As a result, few could articulate the repercussions of changes impacting the

workforce such as new technology, the transfer of care to long-term and outpatient

settings, or California’s rapidly diversifying patient base. While many understood the

value of supporting clinical training sites, they cited mounting cost pressures that may

reduce these opportunities. Ironically, the ability to offer clinical training for allied

health students may be most constrained among teaching hospitals.

If the health care delivery system does not address these and other workforce issues, it

will be at risk of facing greater recruitment and retention challenges and an even smaller

pool of qualified practitioners willing to work in the health care system. Ultimately, these

issues will determine an organization’s viability in the evolving health care environment.

4. The Need to Tie Human Resources to a Quality Strategy

At a time when many health care delivery institutions and systems are recognizing the need

to compete on the basis of quality, few organizations offer a human resources initiative tied

to a quality strategy. The organizations that are doing this are distinguished by their

creativity, resourcefulness and understanding of the centrality of a committed workforce

throughout their organization. This investment and commitment to workforce issues exists

for all members of the health care organization, not just with the highest paid managers or

clinicians. These institutions also showed signs of sustainability, making long-term

investments in education, something lacking in most other health care organizations.

5. Regulatory and Oversight Inconsistency

Regulatory standards that guide the practice of allied and auxiliary workers are

disconnected from the realities of the modern care delivery system. Many federal, state,

7




8 public and private regulatory entities have set new and amended regulatory standards,

resulting in the proliferation of occupations and professions with overlapping scopes of

practice, and a lack of standardization in the regulation of professions and health care

facilities. This has led not only to inefficiencies in the care delivery sector but also to

tensions between some professions.

Compounding these pressures are the challenges that accreditation and licensure present.

Within education, a leadership void exists to challenge out-of-date accreditation and licensure

standards that do not reflect care delivery standards nor quality improvement principles.

6. A Widening Gap Between Education and the Needs of Industry

The educational system that produces allied and auxiliary workers has not offered a

product that meets the needs of either of its dual customers: care delivery institutions and

students. The employers that the Project interviewed cited increasing skill deficits in

their workforce among technical and computer skills as well as critical thinking,

communication, management, delegation and supervision skills, and an orientation

towards teamwork. At the same time, a survey of recent graduates from allied health

educational programs found that a significant number of students felt that they were only

“somewhat” prepared for their jobs in the health care system. When asked to recommend

additional non-clinical skills that allied health institutions should be teaching, recent

graduates indicated a need for computer literacy, interpersonal skills, data and

information systems management, stress management and systems perspectives.

The dearth of visionary programs is a legacy of allied health’s origins within the medical

model of education. Independent allied health faculty, isolated from the professional

realm of the care delivery system, have few vehicles with which to understand the changes

occurring in the emerging health care system. Without a connection to the practice realm,

faculty are challenged to deliver curricula that reflect the care delivery system’s changing

needs. Further, response from the educational system is often too slow, occurring

periodically rather than continually.

7. The Changing Nature of Work and Career Advancement

The fundamental meaning of ‘work’ is beginning to change in the post-industrial, service-

oriented global economy. The concept of a job with discrete tasks carried out over a lifetime


of employment is rapidly disappearing. At all levels — individual, organizational and market

— change appears to be a constant characteristic. With change in the form of downsizing,

the smaller and leaner service sector values a flexible workforce that may be crosstrained in

a number of different functional areas. This has also led to a rise in registries, home-based

businesses, consultants and independent contractors that have replaced traditional full-

time jobs. Further, as workers increasingly find that the skills with which they were formally

trained are either not in demand or become obsolete quickly, the ability to re-tool and

constantly upgrade skills becomes imperative.

For most of this century, work and career have been associated with employment in

large institutions. The changing nature of these institutions means that such connections

will be less common. Rather, individual responsibility for work and professional

development is becoming an increasingly important component of a worker’s success.

Within health care, as well as other service industries, the onus of responsibility for

upgrading skills falls on the individual worker. At the same time that employers express

minimal responsibility for motivating or providing workers with the tools to advance

their careers, workers have grown accustomed to a system of advancement based on

seniority rather than skill enhancement.

Further, while many industries in the late 1980s and 1990s moved to compensation

structures that linked pay with performance, a sizeable portion of the health care

workforce has become accustomed to a generous wage system based on seniority rather

than productivity, particularly within unionized facilities. Yet as health care strives to

meet cost pressures, the pressure to link pay with performance will only intensify.

RECOMMENDATIONS FOR ACTION

The following is a summary of the recommendations (presented in full in Section IX) for

leaders in care delivery organizations, educational institutions, labor unions, the corporate

sector and individual workers to address the specific issues and challenges identified in the

California Twenty-First Century Workforce Project.

The Project concludes that there are a number of challenges that confront the allied and

auxiliary workforce, including new and cross-functional roles and responsibilities,

unsustainable compensation and work environments, and insufficient education and career

advancement opportunities. Although not new, these challenges still remain significant for

9




10


the allied health care workforce. In fact, as the health care system continues its evolution,

the challenges of changing health professions education, utilization and regulation will grow

in importance. The recommendations in this report are aimed at allied health workers but

also extend to the auxiliary workforce, part of the front line workforce that plays a significant

role in the long-term transformation of the care delivery system. Changes in the

demography of the state of California and fundamental changes impacting the nature of

health care, education, and work in the coming decade underscore the importance of these

recommendations and their urgency in preparing this workforce for the next century.

The challenges described throughout the report may be caused in large part because of the

divisions between care delivery, education, labor unions, the workforce itself and other

sectors. Therefore, the following recommendations propose the use of partnerships among

these sectors to address specific issues. Moreover, the collection of data to evaluate the

outcomes of these partnerships and recommended actions is proposed. The seven

recommendations for the allied and auxiliary health care workforce are:

Recommendation 1. Define skill requirements that are aligned with care delivery


competencies, for the allied and auxiliary health care workforce. Require health



Recommendation 2. Expand training and awareness to better prepare the workforce to

deliver health care to an increasingly multicultural society. First, define and develop

competencies for delivering culturally sensitive care for all allied and auxiliary workers.

Second, actively support hiring and training a more diverse workforce.





Recommendation 4. Position the allied and auxiliary workforce in health care

delivery’s strategic process of improving the quality of patient care.










11




12

The changing demographics, work ethic, and organization of work in the United States

influence health care industry dynamics, for they shape the nation’s patient population,

labor pool and market forces. While this Project examined California’s allied and auxiliary

health care workforce, these and other broad state and national trends have already and will

continue to influence and characterize the current and future health care workforce. Therefore,

this report describes many of these larger trends and issues in order to characterize this segment

of the health care workforce and the industry in which they provide health care services.

The health care industry is a system in flux, experiencing increasing pressure to contain

cost and to demonstrate and improve quality. The systems that regulate the industry, health

care professions and care delivery facilities, also are experiencing significant pressure to

respond to evolving provider roles and scopes of practice authority. Moreover, California’s

advanced health care market in which allied and auxiliary workers provide health services

may be a harbinger for changes that will play out in the nation as a whole in the next century.

Over the past 30 years, a variety of societal, demographic and cultural trends have changed

the way the nation views itself and conducts business. These broad forces have shaped

continually the dynamic health care system. Some of these trends, such as the increasing

number of uninsured, the aging population, and the demographics of the baby boom

generation, have direct repercussions on the health care system and health care labor supply.

Factors such as the rapid racial/ethnic diversification of the U.S. and growing gap in the

distribution of income will also impact the health care system on multiple levels. Further,

markedly different values and attitudes exist for the present 25 to 32 year old age cohort which

has recently entered the health care workforce. This group’s values and attitudes, while different

from those of the baby boom generation, also contrast with the next generation of workers.

Perhaps the most transformational trend influencing this sector of the economy will be

the way in which all work is organized, particularly among service sector industries.

Interrelated trends such as the development and use of information technology will also

influence the orientation of the workforce. This broad contextual view of the trends

affecting the health care workforce is discussed in the following sections.


S OC I A L , POL I T I C A L ,T E C H NO L O G I C A L and E C O NO M I CT R E N D S T H AT A F F E C TH E A LT H C A R E

S E C T I O N II

HEALTH CARE IN CALIFORNIA: HARBINGER FOR A NATION

The health care industry is a system in flux, and nowhere are the changes more rapid and

constant than in California. Health care observers often look to California as a laboratory

and harbinger of change for the country. And because the state has a population that is older

and more diverse, with higher levels of uninsurance and welfare than the national averages,

the pressure on California to respond to societal needs and the health care market dynamics

is perhaps more acute than in the rest of the nation.

The challenges confronting the allied and auxiliary health care workforce cannot be

completely understood without an awareness of the industry and the economic, social,

regulatory and technological trends affecting health care delivery. This section of the

workforce report presents seven core forces affecting health care nationwide, as they

manifest themselves in California:

• CONSOLIDATION IN A MANAGED CARE SYSTEM

• INTEGRATION AND A NEW WORKER

• A SHIFTING DEMOGRAPHIC: OLDER AND MORE DIVERSE

• CHANGES IN REGULATORY STRUCTURES

• CONSUMER CHOICE, COMPETITION AND ACCOUNTABILITY

• TECHNOLOGICAL ADVANCEMENT: CLINICAL AND INFORMATION

• THE INDIGENT, UNINSURED AND WELFARE POPULATIONS

While there are many ways one could categorize and explain the myriad forces of change in

health care, these seven trend areas are particularly suited to California. The list was

informed by a recent poll of 38 California health care executives, who were asked what they

were preparing for over the next five years. Responses from this poll are noted throughout

this discussion. Even though managed care has been affecting change for two decades in the

state, these leaders of hospitals, health plans and physician practices anticipated continued

rapid change in the future.

Systems of care, most of them organized by physician groups in response to cost pressure

by health maintenance organizations (HMOs) and aggressive purchasers, have created

entirely new demands for allied and auxiliary health care workers. Work is being redefined

constantly in an attempt to offer patients the most health care for the lowest cost while

13




14 ensuring safety and quality. There are no precedents or guidebooks for this societal change

and no way to predict the outcome. The following orientation on the changes thus far,

however, should offer an invaluable framework for understanding the dynamics of the allied

and auxiliary health care workforce and inform recommendations for its future.

A. C O N S O L I D A T I O N I N A M A N A G E D C A R E S Y S T E M

In response to the growing economic leverage of managed care, health care providers of all

kinds have been consolidating since the 1980s. Physicians have joined group practices,

which have in turn sold to integrated delivery systems or physician practice management

corporations. Hospitals have merged into regional delivery systems that control acute

services as well as primary care and ancillary services. Throughout the industry, players of all

kinds have come to believe that without adequate size, long-term survival cannot be assured.1

A key reason health plans can exert so much leverage is that hospitals are in excess supply.

The Office of Statewide Health Planning and Development (OSHPD) reported a 50.1

percent occupancy rate for California hospitals’ licensed beds in the 1996-97 report

period.2 Hospitals are, as a result, vulnerable to external dictates of price for their services and

level of quality. As both purchasers and plans have organized themselves in a way to make

these demands, providers have had little choice but to organize themselves in response.

These organizations are assembled in two ways. Horizontally integrated systems, such as

Columbia/HCA, are essentially chains of similar kinds of providers, such as hospitals or nursing

homes. Vertically integrated organizations link various kinds of providers together, commonly

hospitals with physician groups, home health companies and pharmacies. Some systems have

pursued both vertical and horizontal strategies simultaneously. Furthermore, many have vertically

integrated services to include the insurance function, though with little measure of success.3

As financing systems evolve, health care leaders from the previous poll stated that they

are especially interested in the future of Medicaid and Medicare. Medicaid, the federal/state

program that finances care for low-income people, has largely shifted to managed care,

on a state by state basis. Medicare, federal health insurance for people over 65 years old,

now has its strongest incentives ever to move beneficiaries into managed care, but the

vast majority of seniors remain in the traditional fee-for-service system. Providers tend to

earn less from treating public patients in managed care, so they view this trend with concern.

On the other hand, health plans see new opportunities in Medicare and Medicaid as contractors.


Most of the respondents in the health leadership survey believed that consolidation would

continue, but most felt that a gold standard describing the ideal system has yet to emerge.

Many pointed to recent failures of large systems, evidence of wrenching transitions, and lost

profitability of hospital systems and provider groups alike as evidence that no perfect model

has emerged to date.

1. STAGES OF MANAGED CARE PENETRATION BY CALIFORNIA REGION

HMO penetration in California is 43.8 percent compared to 26.7 percent nationally.a California

ranked only behind New York for net enrollment growth in HMOs between January 1996 and

January 1997, with a gain of 971,420 members. Further, the percentage of Medicare enrollees in

capitated plans is 38.6 in California and 15.4 in the nation. However, the percentage of Medi-

Cal enrollees in managed care in California, 38.7, is lower than the national rate of 47.8.4

Within California, the present managed care climate varies widely from one region to the

next. To elucidate the environment and trends of state regions (north, south, central and

rural north), certain individual markets are examined which represent or forecast the future

of other communities.

Southern California - Orange County is a fast-moving and decentralized health care market

with high managed care penetration. Estimates show that only five percent of commercially

insured patients still have traditional indemnity insurance. Almost 66 percent of members

of employer-based insurance are enrolled in HMOs. Capitation is the dominant payment

mechanism for primary care services. Given this, physician organizations, hospitals and health

plans are all seeking to increase their size and leverage through acquisitions and mergers.

The county’s employers have been trying to organize themselves into a purchasing coalition

to negotiate with the ten HMOs and numerous preferred provider organizations (PPOs)

and indemnity carriers competing for market share. Furthermore, recent growth of

Medicare managed care and implementation of Medi-Cal managed care is evident in the

county’s new CalOPTIMA program, which aims to expand greatly the number of heath

plans and providers available to this population.5

15



a. It is important to note that Interstudy’s “HMO” definition does not include preferred providerorganizations (PPOs), but it does include open-ended enrollment/point-of-service systems wheremembers can take advantage of their second tier of benefits in seeking service out of the network.Nationally, the total number of people under the umbrella term ‘managed care’ is 165 million, as of July1997; of that, 72 million are insured under HMOs (including Medicare and Medicaid HMOs), and 93million are insured under PPOs or Fee-For-Service indemnity insurance.


16 Another advanced market in Southern California is San Diego, “one of the most mature

health care markets in the nation on the basis of network development and managed care.”6

San Diego hosts three large health care organizations — Sharp HealthCare, ScrippsHealth and

Kaiser Permanente — along with 11 health plans affiliated with large national or California-based

insurers. Of the insured population, nearly 35 percent belong to an HMO, and approximately

95 percent are enrolled in some form of managed care, primarily PPOs. It has also been

estimated that 60 percent of the commercial health insurance market is now capitated.7 The

fierce competition for market share has driven health plans to grow either through merger and

acquisition or through price-based competition. However, no quality assessment/ evaluation

system exists to differentiate one plan from another in the eyes of the consumer.8

Northern California - The Greater Sacramento area, which includes the counties of

Sacramento, Yolo, Placer and El Dorado, has a substantially advanced health care market.

The Greater Sacramento health system is affected greatly by the trends set by two powerful

purchasing coalitions: the California Public Employees Retirement System and the Pacific

Business Group on Health. Since 1992, the shift by employers to competitive purchasing of

health care services has resulted in a decline in employer-based HMO premiums and a

substantial reorganization among hospitals and physician organizations. Furthermore, the

Greater Sacramento area has high managed care penetration, with more than 60 percent of

the population enrolled in an HMO as of the end of 1996; this high HMO enrollment

includes a large majority of Medicare beneficiaries and almost half of Medi-Cal recipients.9

Three-fifths of the HMO market is concentrated in Kaiser Foundation Health Plan and in

Health Systems International/Foundation Health.

Hospital systems in this area are fairly concentrated as well, with four not-for-profit

systems accounting for 95 percent of all hospital bed-days: Kaiser, Sutter Health, Mercy

HealthCare Sacramento and University of California, Davis. Another sign of the area’s high level

of managed care penetration is the measure of hospital days per 1,000 persons — 521 per 1,000

persons in the Greater Sacramento area versus 796 nationwide. Primary care physicians

are highly organized into ten major physician organizations, which are controlled or

owned by six firms. The shift to paying provider organizations capitation rates in this area

has only occurred in the past few years. Despite the advances in the health care market, there

is no empirical evidence on whether quality of care has improved, and there is a lack of

quality measures.10


Central Valley - California’s Central Valley has a moderate level of managed care

penetration, less advanced than the urban northern and southern California regions. The

percent of the population enrolled in an HMO in Bakersfield, Fresno, Modesto and

Visalia-Tulare-Porterville is 22.3, 29.1, 26.6 and 23.0, respectively. These numbers usually

fall at least ten percentage points below those for major southern and northern California

metropolitan statistical areas. Outside of the Fresno area, which has a moderate amount of

managed care, the rural regions have little or no managed care penetration.11

However, within the Central San Joaquin Valley, four major integrated delivery systems,

namely Kaiser Permanente, St. Agnes-Priority Health Services, Community Hospitals of

Central California (now Community Health System) and Valley Children’s Hospital-

ChildNet are the main providers of medical services in the region. These four integrated

delivery systems are also all affiliated with at least one commercial managed care organization.

Major providers in the region also include community health centers, county and state

health care facilities and the Department of Veterans Affairs (VA) Medical Center.12

Rural Northern California - The percentage of managed care penetration in rural Northern

California is also not as high as the more mature southern and northern California

managed care markets. HMOs have been wary of entering rural counties for various reasons,

such as physician shortages and the difficulties that present in establishing networks,

problems with financing fixed costs, fluctuating Medicare reimbursements and difficulties

with marketing strategy.13 While Medicare recipients who choose HMO coverage effectively

transfer their coverage from Medicare to the HMO, premiums are typically lower in rural

areas and are limited to annual increases of two percent.14 The Contra Costa Times reported

that Medicare payments are “generally higher” in Southern California than in northern or

rural parts of the state. The amount of reimbursement for a Los Angeles County member

is $635 per month, but it ranges between $490 and $583 for a northern California county

member.15 For these reasons and more, there is a statewide trend of Medicare HMOs

withdrawing from mainly rural counties.

As of July 1998, Health Net, California’s third largest Medicare insurer, behind

PacifiCare and Kaiser Permanente, planned to end its Medicare contracts in nine rural

counties in Northern California to combat the low reimbursement rates in rural markets.16

Similarly, Blue Shield has decided to stop signing up new Medicare HMO members in

Northern California because reimbursement rates are often much lower than the actual

17




18 costs of caring for patients there.17 Foundation Health Systems, Inc., a Woodland Hills-based

company, is also pulling out of Medicare programs in ten rural northern California counties.18

In contrast, several health plans in the north valley have been awarded contracts to

participate in the new children’s health insurance program in Butte County. The three

health plans — Blue Cross’ Exclusive Provider Organization, Health Net and California

Advantage — now participate in the Healthy Families Program. However, only Blue Cross

has won the preferred status of ‘community provider plan’, which means that families that

use the community provider will save between one and three dollars per month.19

2. CONSOLIDATION OF HOSPITALS AND HEALTH PLANS IN CALIFORNIA

Some of the greatest costs in health care expenditures have occurred in the acute care setting.

Consequently, hospitals have experienced pressures to contain costs earlier and to a greater

extent. Mechanisms to control health care spending include shifting care to other care

delivery settings and management changes. Given these realities, hospital systems and

managed care organizations have exhibited some of the most dramatic responses.

Nationwide in 1996, there were 768 hospital mergers, and California had more than any

other state that same year, with a total of 30.20 Between 1990 and 1997, the number of

independent hospitals in the state of California declined by 11.8 percent, from 596 to 533

facilities. The number of licensed beds also reflects this trend, decreasing from 124,319 in

the 1989-90 report period to 119,326 in the 1996-97 report period.

The dominant health systems emerging in California are Catholic HealthCare West,

Columbia/HCA, Kaiser Permanente, Sutter and Tenet/NME, together owning

approximately 28.0 percent of hospitals in the state (an increase from 10.1 percent

collectively in 1989-90). With the exception of Kaiser Permanente, between 1989 and

1998, the number of hospitals each system operates in California increased. Catholic

HealthCare West grew from 5 to 35 hospitals, Columbia/HCA acquired 17 hospitals, Sutter

expanded from 7 to 25 facilities, and Tenet/NME expanded from 20 to 45 hospitals in

1998. This increase in the number of facilities and the percentage of the total number

of hospitals in the state these represent are presented in Exhibit 1.

Consolidation has also occurred at the health plan level where a small number

of HMOs represents an increasing number of the insured population. Nationally,

the number of HMOs has increased significantly since 1976 and then declined


since 1987.b In 1976, there were 175 HMOs with a total of 6 million enrollees. The number

of HMOs increased to a peak in 1987 with 650 organizations across the nation and 29.3

million enrollees. In 1995, there were 591 HMOs in the country, a decrease in the number

of plans from 1987, yet these plans had a total of 59.1 million enrollees.

In California, while the number of HMOs has increased from 30 in 1989 to 40 full-

service plans in 1998, the number of enrollees in these health plans has increased approximately

165.0 percent. In 1989, the 30 HMOs represented 7.6 million enrollees,21 and the current

number of enrollees in HMOs is 20.1 million.22 Signifying consolidation among the largest

HMOs in the state, 5 of the 40 health plans account for 77.2 percent of the total state

enrollment in 1998. These five plans are Kaiser Foundation Health Plan, Blue Cross of

California, Health Net, PacifiCare and Blue Shield of California.

3. IMPLICATIONS FOR THE WORKFORCE

As health plans and hospitals consolidate, the allied and auxiliary workforce is affected in

many ways. First, more treatment and care is being provided to patients in managed care

plans. How this affects the amount and type of care that will be reimbursed by health plans

is becoming crucial for all health care providers to understand. Given the consolidation of

acute care hospitals, more allied and auxiliary health care workers will be asked to shift to

outpatient or other non-hospital health care settings.

19



Source: 1989-90 and 1995-96 Office of Statewide Health Planning and Development (OSHPD) disclosure reports. 1998 Hospital and Health System Survey.

California Medicine Special Supplement. July 1998. Note: Total Number Of Facilities (n=533) from 1997 OSHPD data used to calculate percentage for 1998.

TOP FIVE HEALTH SYSTEMS IN CALIFORNIA

45

40

35

30

25

20

15

10

5

0

NU

MB

ER

OF FA

CILITIE

S

CatholicHealthcare West

Columbia/HCA Kaiser Sutter Tenet/NME

1989-90 OSHPD

1995-96 OSHPD

1998 CA Medicine Survey

0.0%

3.2%

8.4%

6.6%

2.6%

0.8%

1.7%

4.9%4.7%

1.2%

3.4%

5.1%

2.2%

4.7%4.8%

b. The nationwide number of HMOs is tracked by the Group Health Association of America.

E X H I B I T 1: Hospital Consolidation in California - Number of Facilities and Percent of California Total


20 B. I N T E G R A T I O N A N D A N E W W O R K E R

Consolidation of providers may help resolve the fragmented health care system and

coordinate care across providers and populations. However, only a handful of particularly

well-run systems around the country have achieved this. Typically, integration affects a fairly

narrow range of activities, such as the provision of specialty services. Less than 60 percent

of HMOs have a functional asthma disease state management program, and the numbers are

lower for other prevalent disease states such as diabetes and depression.23

In the health care executives poll, the fragmented financing system was identified as a

source of the failed efforts at integration. Others attribute problems more to the poor skill

level of employees within organizations who are not prepared to manage the change process,

take on new roles or form new partnerships with other practitioners. Nonetheless, active

experimentation toward more integrated approaches will continue.

Hopes that integration will prosper in the future derive from a revolutionary change in

the nature of work going on in the rest of the economy. The new face of work has evolved

from the transforming U.S. economy and its impact on the American workforce. Some of

these changes are due to tax laws representing a less progressive distribution of income

although the major change has been and will continue to be the loss of high wage industrial

jobs that characterized the economy from 1925 to 1975. Essentially, these jobs have gone to

other countries, or they are performed by smaller numbers of more productive laborers

deploying sophisticated skills and using expensive capital inputs. This reformation is a by-

product of the U.S. economy’s shift from an industrial economy to a service-based economy

heavily dependent on information and technology.24

These changes are also reflected in a revolution of the 1980s and the early 1990s in which

the newly dominant service sector began de-emphasizing full-time employees and drawing

sustenance from a contingent workforce that includes part-time workers, consultants and

outsourced services and personnel. For instance, a recent study of California workers found

that less than half of California’s adults are employed full-time, while 19 percent work part-

time, 7 percent are unemployed, and 34 percent are out of the labor force.25 For those

working, this modern service sector values a flexible workforce that may be crosstrained in a

number of different functional areas. Further, as workers increasingly find that the skills

they were trained with are obsolete, the ability to re-tool and constantly upgrade skills

becomes imperative. This has led to a rise in home-based businesses, consultants and


independent contractors that have replaced many permanent jobs. At the broadest level, the

fundamental meaning of work has changed in this new environment. The concept of a job

with discrete tasks no longer exists. At the individual, organizational and market levels,

change is now constant.26

For the generation now entering the workforce, this shift to a service-based economy

offers a significantly different labor market than their predecessors knew. Despite the fact

that the number of college graduates continues to grow, it has been predicted that there will

be fewer job openings requiring a college degree during the 1990s than there were in the

1980s. High school graduates entering the workforce face even grimmer prospects, as they

earn approximately 27 percent less than their peers did in 1979.27

Most job growth from 1996 to 2006 is predicted to increase in two very distinct areas at

opposite ends of the educational attainment and earnings spectrum. During this period,

professional specialty occupations are projected to increase at the greatest rate (27 percent),

adding 4.8 million jobs. At the other end of the spectrum, service sector jobs are expected

to add 3.9 million jobs over the 1996 to 2006 period. Combined, these two groups

represent 46 percent of all job growth from 1996 to 2006.28 The jobs of the future will

exist under two different organizing principles at opposite ends of the job spectrum.

One end covers repetitive, systematized work whereas the other end encompasses the

flexible, disintegrated and entrepreneurial work. The task at hand is fitting the right

people to the right work.29

Implications for the Workforce - Work in the next millennium will be more fluid, flexible,

knowledge based and individually motivated. In the health care executives poll, leaders raised

concern about whether the health care workforce will be flexible enough to carry out the

perceived need for workplace redesign. This concern is often coupled with anxiety over whether

the professional associations and unions will be open enough to allow workforce redesign.

Some in the leadership survey specifically identified nursing supply as critical, and some

respondents recognized other workers on their staff as inadequate either in number or

competency. In general, many expressed concern that the nature of health care work was or

would be changing and that the workforce would not be ready. There was also concern

expressed that physicians could not be counted on to play the needed leadership roles in

the transition.

21




22

C . A S H I F T I N G D E M O G R A P H I C : O L D E R A N D M O R E D I V E R S E

Nationwide, and to an even greater extent in California, the population is growing older

and more ethnically diverse. These demographic trends pose difficult questions that touch

on the economics of health care delivery and on the system’s ability to serve the needs of the

community. Most of what is known about the demographics and dynamics of a diverse health

care workforce and service to diverse populations comes from research about doctors and

nurses. Parallel research should be conducted for the allied and auxiliary workers. But, the

physician and nursing research can provide insight into these dynamics.

1. AN AGING SOCIETY

Between 1990 and 1996, the total elderly populationc increased 10 percent nationally and

12 percent in California.30 The most significant increases occurred for persons over the age

of 75. According to the Bureau of Labor Statistics, the population of persons between the

ages of 75 to 84 increased 18.3 percent nationally and 20.2 percent in California.

Additionally, the number of persons 85 years of age and older increased 31.1 percent in the

U.S. and 26.7 percent in California. (See Exhibit 2)

The U.S. Bureau of the Census projects that the nation’s elderly population will increase

by another 17 percent between 1995 to 2010. However, due to the aging of the baby boom

generation, this population is projected to increase by 76 percent between 2010 to 2030.


35%

30%

25%

20%

15%

10%

5%

0%

Source: U.S. Bureau of the Census–Population Division. U.S. Population

Estimates by Age, Sex, Race, and Hispanic Origin: 1980 to 1997

(with Extension to May 1, 1998).

AGE

10.0%12.0%

1.2%

5.7%

18.3%20.2%

31.1%

26.7%U.S.

California

65+ 65-74 75-84 85+

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: U.S. Bureau of the Census (1996a) Population Projections

1995-2010 2010-2030 2030-2050

17%

76%

14%

YEAR

c. The elderly population is defined as persons 65 years of age and older.

E X H I B I T 3: Projected Percent Increase of Total ElderlyPopulation (Defined as 65 years of age and older)

E X H I B I T 2: Percent Increase of Elderly Population,United States vs. California, 1990 to 1996

Between 2030 and 2050, the elderly population is expected to return to a more moderate

increase of 14 percent.31 (See Exhibit 3)

Given that persons 85 years of age and older have a higher demand for medical care, these

are expensive demographics. In a 1995 survey, 90 percent of the 1.5 million residents in

nursing homes were 65 years of age and older, of whom more than a third were 85 years of

age or older.32 A 56 percent increase of the population 85 years of age and older is expected

to occur between 1995 to 2010, and this change is expected to be quite dramatic between

2030 and 2050 when this population is expected to increase by 116 percent.33 This increase

means that, if residency ratios in nursing homes remain the same, the total number of

persons residing in nursing homes could double or triple by 2030.34

2. AGE AND THE WORKFORCE

The baby boom and subsequent “baby bust” of the late 1960s and 1970s presents a number

of challenges for workforce planners. The Bureau of Labor Statistics (BLS) projects that the

overall labor force of 25 to 34 year olds will decline by nearly 3 million between 1996 and

2006. However, within the same time period, the 45 to 54 year old cohort will increase by

nearly 9 million workers, and the 55 to 64 year old segment will increase by over 6 million

workers.35 (See Exhibit 4)

Attitudinal differences regarding work among these age cohorts have significant

implications. The Great Depression and World War II greatly affected the generation born

before 1945 (termed by marketers as ‘the mature generation’). “Discipline, self-denial,

23



10

8

6

4

2

0

-2

-4

-6

Source: Bureau of Labor Statistics. Civilian Labor Force by Sex, Age, Race and Hispanic Origin, 1986, 1996 and Projected to 2006. Monthly Labor Review,

November, 1997:1.

AGE GROUPS

CH

AN

GE

IN N

UM

BE

R O

F WO

RK

ER

S IN

LAB

OR

FOR

CE

(MIILLIO

NS

)

16 to 19 20 to 24 25 to 34 35 to 44 65+45 to 54 55 to 64

E X H I B I T 4: Projected Change in Number of Workers in United States Labor Force by Age Group, 1996 to 2006


24

financial and social conservatism and sense of obligation” characterize this generation,

contrasting greatly with Baby Boomers who were “nurtured in the bountiful post-war period

and who believe that they are entitled to the wealth and opportunity that seemed endless

during their youth.”36 Following the Boomers, Generation X sees the world from a much

different vantage point. Now in their 20s and early 30s, many of the young people in this

generation were raised in single parent or dual income families and grew up in the age of

AIDS, greater racial and ethnic diversity, dramatic economic change, corporate downsizing,

rising violence and the awareness that stability is hard to find. These experiences instill

different attitudes and values that may be reflected in how these individuals approach and

participate in education and the workforce.

3. ETHNIC DIVERSITY

As the patient population in California diversifies, the health care delivery system faces a

number of challenges in providing culturally competent care. These vary from recruiting

bilingual practitioners to developing a greater understanding of the prevalence and patterns

of disease across ethnic and racial groups, and communicating different beliefs about

wellness, disease and treatment.

Non-white populations are the fastest growing segments of the U.S. population, comprising

approximately 26 percent of the nation’s population. From 1990 to 1998, the White population

decreased from 77.0 percent to 74.3 percent. Black and American Indian/Eskimo/Aleut

representation, 11.4 percent and 0.8 percent of the population, respectively, remained the same.


White Black American Indian/Eskimo/ Aleut

Asian/PacificIslander

Hispanic

80%

70%

60%

50%

40%

30%

20%

10%

0%

Source: U.S. Bureau of the Census–Population Division. U.S. Population Estimates by Age, Sex, Race and Hispanic Origin: 1980 to 1997.

77.0%74.3%

11.3% 11.4%

0.8% 0.8% 3.4%2.8%

8.3% 10.1%

1990

1998

E X H I B I T 5: Ethnic/Racial Composition of United States Population, 1990 to 1998P

ER

CE

NTA

GE

OF P

OP

ULATIO

N

During the same period, Asian/Pacific Islander and Hispanic populations increased from 2.8

percent to 3.4 percent and 8.3 percent to 10.1 percent, respectively.37 (See Exhibit 5) According

to the U.S. Census Bureau projections, non-white populations will make up 32 percent

of the total population by the year 2010 and 47.2 percent by 2050, just shy of a numerical

majority.38 In addition, during the 1990s, the foreign-born population increased by 30

percent, an increase greater than the overall increase of the U.S. population by 8 percent.

The diversification of California is seen particularly within Asian/Pacific Islander and

Hispanic populations. While representation of the Black and American Indian/Eskimo/Aleut

population remained relatively constant from 1990 to 1996, the Asian/Pacific Islander and

Hispanic populations increased from 9.2 to 10.8 percent and 26.0 to 30.2 percent of the

state’s population, respectively. During these years, White representation decreased from

57.1 to 51.7 percent. (See Exhibit 6)

An important aspect of the nation and state’s growing diversity is the disparity of health

status and access to health care among the racial/ethnic populations. It is a concern that this

disparity may worsen as the nation and state continue to grow more diverse. Significant

differences in the health status of various racial, ethnic and socioeconomic populations exist

in California and the U.S. For example, in California, the age-adjusted mortality rate per

100,000 people was 771.4 for Blacks, 473.1 for Whites, 363.7 for Hispanics and 309.2 for

Asians/Pacific Islanders and other non-whites.39 Furthermore, approximately 14 percent of

Blacks, 15 to 50 percent of Asian/Pacific Islanders, and 37 percent of Hispanics are

uninsured, compared to 12 percent of Whites.40

25



60%

50%

40%

30%

20%

10%

0%

Source: U.S. Bureau of the Census–Population Division. U.S. Population Estimates by Age, Sex, Race and Hispanic Origin: 1980 to 1997.

57.1%

51.7%

7.1% 6.7%0.6% 0.6%

10.8%9.2%

26.0%

30.2%

White Black American Indian/Eskimo/ Aleut

Asian/PacificIslander

Hispanic

1990

1996

E X H I B I T 6: Ethnic/Racial Composition of California Population, 1990 to 1996


26 4. IMPLICATIONS FOR THE WORKFORCE

Studies have shown that a diverse health care workforce increases access to care for

traditionally underserved populations. One such study found that the most powerful

predictor of whether a physician will practice in an underserved area is his or her race or

ethnicity. This study confirmed that non-white patients receive the highest levels of service

from young physicians of the same race or ethnicity. Furthermore, both Black and Hispanic

physicians consider approximately 40 percent of their patients to be “poor.”41

This and other studies underscore the importance of diversity within the health

professions, arguing for a larger supply of underrepresented non-whites within medicine,

nursing and allied health. The 1998 Council on Graduate Medical Education report called

for two parallel responses to address the high percentage of non-whites needing better access

to health care: enlist greater numbers of non-white physicians into the workforce; and train

all physicians to become culturally competent to care for all populations. Today’s health

providers must be prepared to care for a population with markedly different patterns of

disease and health care needs based on their various cultures. This call to action is intended

to counteract the present disparity in non-white representation in the physician workforce.

Although Blacks, Hispanics and American Indian/Eskimo/Aleuts constitute 21 percent of

the total population, this non-white population represents only 12 percent of entering

allopathic and osteopathic medical students, 7 percent of practicing physicians and only 3

percent of medical faculty.42

Research suggests a relationship between population demographics and the location of

training programs, which, in turn, may influence where health personnel are employed. In

the late 1980s, when concerns about an inadequate supply of primary care physicians and

allied health personnel in rural areas surfaced, federal and state governments designed and

implemented training projects in rural communities. A 1992 study found that allied health

education is offered in almost 2000 locations in the U.S., but only 40 percent of all non-

metropolitan counties have one or more accredited programsd or training sites. More

significantly, however, the study found that counties with a shortage in physicians have a

shortage or complete lack of health training resources. In terms of sociodemographic

characteristics, counties that grew rapidly over the last decade or have higher numbers of


d. These accredited programs were determined by the Committee on Allied Health Education and Accreditation.

Hispanics are less likely to have allied health training locations than those that grew slowly or

have lower numbers of Hispanics.43

With this finding in mind, exploring the link between allied health training sites with

subsequent practice locations becomes paramount.44 Rural-based institutions tend to enroll

a higher proportion of their students from rural backgrounds and/or those inclined toward

rural practice.45 Studies showing that there is usually higher placement and retention of

allied health personnel in the same rural area as the training site implies potential for

improved access to care for underserved populations and more health career opportunities

for rural residents.46 Thus, a targeted expansion of allied health education resources in

underserved areas should improve access to health care.

For the future workforce, health education programs should make racial/ethnic diversity

a priority. Non-white representation in the allied health education field is substantially

lower than that of Whites in accredited educational programs. Disparities in enrollment of

non-whites in individual programs are good indicators of the disparities within the current

allied health workforce. In the academic year 1991-92, the total enrollment of non-whites

in programs of allied health was 22,675, compared to the White enrollment of 85,409.

However, non-white enrollment varies by occupation. For example, non-white enrollment

is lowest in anesthesiologist assistant, medical illustrator and blood bank technologist

programs, while White enrollment in those areas is about five times greater. Areas of greatest

disparity in enrollment are in occupational therapy, perfusionism and radiography where

there are almost ten times as many Whites as there are non-white enrollees.47

As for total non-white enrollments for all allied health programs, there was a 51.3 percent

increase from the academic year 1988-89 to the academic year 1991-92. However, the ratio

of non-white enrollment to White enrollment still decreased slightly. This indicates a

moderate decline in the representation of non-white groups in allied health, in contrast to

the growing representation of non-white groups in the U.S. population.

Studies have shown that affirmative action has increased the number of non-whites in

medicine. (Again, this section references physician workforce research on the impact of

affirmative action on the medical profession and its subsequent effect on health status since

minimal research exists for allied health.) The subsequent link comes in the fact that non-

white physicians have been shown to serve patients of their same race/ethnicity, who

traditionally reside in underserved areas. These two strong links suggest a beneficial

27




28 association between affirmative action and improved health care access in underserved areas.

However, the lack of research and the innate difficulty in measuring health status has made

it impossible to link affirmative action directly with the improved health of a community.48

D . C H A N G E S I N R E G U L A T O R Y S T R U C T U R E S

Health care is one of the most heavily regulated businesses in the U.S. Like every other state,

California is affected by an overlapping and often fragmented set of federal and state

regulatory regimes whose internal conflicts and complexities are becoming increasingly

important factors in reconfiguring the health care workforce.

There are five general categories of health care regulation: (1) the regulation of people or

professions, including scope of practice authority and entry into a profession; (2) the

regulation of health care facilities, including the physical facility requirements and the

minimum standards for the number and categories of providers working in the facility; (3)

the regulation of health care products, such as pharmaceuticals, devices and equipment; (4)

the regulation of reimbursement policies for health care services, including screening for

health care fraud; and (5) the regulation of health insurance plans, including solvency

standards and requirements for consumer protection. This section outlines the regulation

of professions and occupations, and provides examples of regulatory overlap and conflict

that affect the workforce.

1. REGULATION OF PROFESSIONS AND OCCUPATIONS

The regulation of a profession or occupation includes both public and

private entities which:

• accredit educational programs that provide entry-to-practice training;

• establish minimum standards and requirements for entry-into-practice;

• protect the use of occupational titles;

• define a profession’s scope of practice authority;

• define requirements for continuing education; and

• establish mechanisms for investigation and disciplinary action for

substandard practitioners.


At a minimum, regulation of people or the workforce provides standards for entry into

health care occupations and professions, initial and continuing competence of providers,

safe health care practices, and disciplinary action for violators of the requirements. Each of

these provisions plays a role in protecting patients. Some of the allied health care workforce

are licensed (with defined scopes of authority to practice and deliver particular health care

services as well as title protection).Others are certified by a public or private entity (with

specified educational requirements to use a particular occupational title). Still others are

simply state-registered. The recognition and definition of each profession may differ from

state to state. Also, some unlicensed occupations may pursue licensure or other regulatory

protection. This process of regulation typically occurs state by state, and can be met with

opposition from professions that already have defined scopes of practice authority and other

regulatory protection.

Accrediting Bodies for Education - There are private entities established to accredit educational

programs that prepare particular health care providers. These accrediting bodies include the

Commission on Accreditation of Allied Health Education Programs. These bodies are

described and issues related to accreditation are addressed in Section VII of this report.

Regulatory Entities for Health Care Practice - Most regulatory entities serve to protect health

care consumers on the receiving end of health care practice. In California, one health

profession regulatory body is the Department of Consumer Affairs (DCA), which

establishes minimum qualifications and levels of competency for licensure, certification or

registration of practitioners. The DCA, comprised of 36 entities that license more than 180

professions, also investigates consumer complaints and disciplines violators of the

professions’ regulation. Examples of allied health care professions and their respective

governing bodies are: respiratory care practitioners (Respiratory Care Board); medical

assistants and midwives (Medical Board of California); social workers and counselors

(Board of Behavioral Sciences); veterinary technicians (Veterinary Technician Examining

Committee); and physical therapists and physical therapist assistants (Physical Therapy

Board of California). Some of these entities represent specific occupations and function

autonomously, such as the Physical Therapy Board. Other boards are adjuncts to larger

entities, which represent multiple occupations such as medical assistants and nursing

midwives who are governed by the Medical Board of California. Other professions are

regulated generally by the DCA without their own bureau, program, board or committee.

29




30 These different regulatory structures have implications for the consumers, employers and

the personnel employed in these occupations.

The Department of Health Services (DHS), which also licenses health care facilities and

certifies those that are eligible for payments under the Medicare and Medicaid programs, is

another state entity which oversees some of the allied health professions. The DHS oversees

several types of clinical laboratory personnel, including clinical laboratory scientists and

cytotechnologists. These agencies not only set and oversee requirements for entry into

particular professions, they also may set requirements for and accredit educational

programs to train professionals. This can be viewed as indirect, but related governance of

professions to ensure qualifications of practitioners.

Requirements for Continuing Education - For many allied health care personnel, in addition to

educational and practice-related regulation, there are mandatory continuing education

requirements. These requirements, usually set by public entities, typically include 12 to 24

hours of education per year or every two years at an accredited institution. Care delivery

institutions often provide funding and/or time off work to ensure that their employees meet

their respective continuing education requirements.

However, continuing education requirements often do not reflect current health care

practice standards. The value of continuing education requirements as they are currently

structured has been questioned. At issue is whether the mechanism for continuing education

could be restructured as a system for demonstrating competency, which would be more

applicable to health care practice standards. With increasing focus on health outcomes and

quality, regulation of health care facilities is beginning to call for providers to demonstrate

competencies both in new functions as well as on an ongoing basis.49

Unlicensed Occupations - While unlicensed occupations do not have many of the regulatory

requirements described above, some of these occupations do have accrediting bodies that

provide some protection. For example, the Commission on Accreditation of Allied Health

Education Programs has accrediting bodies that define training requirements for some

unlicensed personnel. Still other auxiliary occupations such as unlicensed assistive personnel

and environmental support services personnel who are not registered, certified or licensed,

do not have access to regulatory protection. Training for such personnel is provided on-

the-job, and recognition of training and continuing training may vary widely among occupations

and health care settings. For these personnel, the care delivery facility also carries the full


responsibility for their competency. Thus, the documentation of on-the-job training takes on

increasing importance in light of the emphasis on health care facility regulation.

2. EXAMPLES OF UNCOORDINATED REGULATION

With numerous participants in the regulatory environment, it is not surprising that some of

the regulations are uncoordinated and even conflicting. For example, there is overlap in the

scopes of practice defined for physical therapists and occupational therapists. At the health

care facility level, employers may designate physical therapists to provide care traditionally

provided by occupational therapists. This overlap inevitably leads to questions about what is

ethically right on the part of the physical and occupational therapy practitioners and what

provision of care is the highest quality on the part of the patient.

In addition to overlapping scopes of practice authority, contradictions exist between

facility regulation and particular professions’ scopes of practice. For example,

California state lawe and federal law set forth in the Clinical Laboratory Improvement

Amendment of 1988 (CLIA) define exempt, registered and licensed laboratories and

the personnel, along with their respective competencies, who can perform types of

laboratory testing. In practice, these regulations have meant that some allied health care

workers or student interns in training who previously performed lab testing may not

meet current requirements. While these laws have been set, the Respiratory Care Board

meanwhile set forth its own guidelines, determining that all laboratory testing falls within

the scope of practice of a respiratory care practitioner.

These independent regulatory actions may not be compatible. For instance,

disagreement exists over whether the respiratory care practitioners’ scope of practice and

education meet the requirements for moderate complexity level tests, which include a

minimum number of laboratory science units as well as particular competencies

demonstrated under the direction of a laboratory director. Furthermore, while the clinical

laboratory regulation mandates competency demonstration, there are not uniform systems

in place to carry this out among the allied health care professions. And while CLIA defines

who can perform point-of-care testing, it does not mandate who conducts training and at

31



e. The California state law refers to amendments and additions to Chapter 3 of Division 2 of the Businessand Professions Code relating to clinical laboratories.


32 what frequency. Thus, it is left to individual care delivery facilities to define and carry out

competency demonstration and training mechanisms.

Other laws can allow allied health care workers to perform functions that they previously

were not authorized to do. California state lawf allows radiologic technologists under the general

supervision of a physician to perform venipuncture in an upper extremity to administer

contrast materials for imaging. Previously, radiologic technologists were allowed only to

assist in these procedures, creating some inefficiency. These changes in regulations expand

technologists practice and directly impact the allied health care workforce and their training.

However, it should also be noted that the practice of venipuncture by technologists overlaps

with some nursing professions’ scopes of practice, and this may create new tension.

Among the allied health professions, there is lack of uniformity among states regarding

licensure. For example, occupational therapists do not have to be licensed in all states. Also, the

mid-level medical laboratory technician (MLT) with an associate degree is formally recognized in

44 states, though not in California. Thus, it is difficult for many practitioners to move from

one state to another and continue in their respective fields of practice. In fact, MLTs from other

states who move to California may work as unlicensed laboratory assistants with less capacity

and salary compensation. To note, the DHS — Laboratory Field Services division has put forth a

proposal calling for the MLT occupation, with the aim to become a state law in the year 2000.


Without an effort to bring uniformity to the regulation of allied and auxiliary health

professions, providers will not be able to practice to their fullest capacity. Future regulatory

activity not only needs standardization across entities and levels, but also must be founded

on research data and outcomes. The allied health professions and the care delivery

employers will therefore need to support, conduct, and evaluate research to determine

which providers should provide care and how the highest quality and most cost-effective care

can be provided. For example, if a mid-level MLT is found to conduct certain laboratory

testing accurately and more cost-effectively than the medical laboratory technologist, this

profession could then be recognized in this state. Furthermore, regulators need to

encourage the professions and employers in these research and evaluation activities.


f. The California state law refers to amendments to Section 106985 of the Health and Safety code relatingto radiologic technology.

In the report of the Pew Health Professions Commission’s Taskforce on Health Care

Workforce Regulation, one recommendation called for “demonstration projects that allow

practitioners to safely provide care that lies beyond their current statutory authority with the

goal of collecting data on the quality and costs of care so delivered.”50 Such projects could provide

the data and evaluation that are needed to coordinate the regulation of this segment of the

health care workforce.

E . C O N S U M E R C H O I C E , C O M P E T I T I O N A N D A C C O U N T A B I L I T Y

Most of the changes in the health care system over the last ten years have been the result of

market forces. For a century, the U.S. health care system was relatively insulated from traditional

economic constraints, but as employers saw their health care costs spiraling out of control in

the 1980s, they brought new pressure to bear on insurers. This more active approach to

purchasing has filtered down to the individual consumer level for two reasons. Private and

public purchasers of insurance have often attempted to provide their workers or beneficiaries

with a choice of health plans and new insurance options. For example, medical savings accounts

offer consumers more choice with respect to the providers they see than traditional managed

care. In addition, consumers have more information than ever before with which to select a

health plan and provider. This market is imperfect, but rapidly evolving, and market-based

competition for patients is now regarded as one of the bellwethers for health system change.

An important manifestation of this consumer consciousness has been a move to document

health outcomes at a plan and provider level. It is hoped that this trend, through which

consumer “report cards” are developed, will be accelerated by a move toward capitation or

risk sharing. This is when health plans shift insurance risk to provider groups by giving them

a flat amount per patient per month and leaving the providers to make all medical decisions.

In the best cases, these arrangements let providers become stewards of the health of their

patient population and indeed for their entire service area, since they benefit economically

from improved public health.

Health care executives, in the poll, reported being aware of new degrees of institutional

responsibility and accountability for patients’ or members’ health and well being. Most view

this change less as a burden than an opportunity for institutions to demonstrate efficacy in

a market that would increasingly support the selection of those systems that could, in the

words of one respondent, “stand for something.”

33




34 At the employer level, California has a long history of purchasers demanding the most for

their money. Their main tool has been purchasing cooperatives, which, according to one

report, “negotiate with health insurance plans on behalf of participating employers and, in

some cases, purchase and administer coverage for these employers, often on behalf of several

hundred thousand employees and dependants.”51 They have also sought to improve the

quality of health care services which employees and their dependents receive.

Purchasing cooperatives have stimulated competition among health insurance plans

by negotiating aggressively over premiums, instituting standard benefits packages and

requiring plans to comply with quality standards. For example, in recent years, three of

California’s purchasing cooperatives have held annual increases in health insurance

premiums well below the national average and, in some cases, have even negotiated

reductions in premiums.52

Three main purchasing cooperatives shape California’s health care system: Pacific Business

Group on Health (PBGH), Health Insurance Plan of California (HIPC) and California

Public Employees Retirement System (CalPERS). PBGH, a non-profit coalition of large

corporations, is the largest of the three purchasing cooperatives and is probably the most

responsible for reducing premiums in California. The HIPC offers leverage in purchasing

power for smaller businesses. CalPERS is the main coalition in the public sector for

administering health insurance benefits for California’s state and local government employees.

However, purchasing cooperatives are not the only means by which employers are shaping

health care delivery. Employers are also giving their employees incentives to enroll in HMOs

instead of fee-for-service or preferred provider organization (PPO) plans, thinking that

HMOs are better able to control health care costs. The trend is toward the adoption of

incentives similar to those created by the University of California, one of the state’s largest

employers. “University of California employees contribute substantially less to health

insurance premiums and are charged lower co-payments for health care services if they

enroll in HMOs instead of in PPOs or fee-for-service plans.”53

However, recent reports show California facing a cycle of premium increases despite the

past years of controlled costs. Due to health companies’ losses, high drug prices, increased

shareholders’ profits, negotiations between hospitals and HMOs, and new laws, employers

must pay higher health premiums. Eventually, the workers and consumers feel the brunt of

the additional costs incurred.54


Implications for the Workforce - As the power of the consumer of health care services grows,

the health care workforce will increasingly be measured by what it contributes to meeting the

needs of consumers. The level of consumer satisfaction is and will continue to be important

to individuals and corporate consumers of health care. This will mean that higher levels of

accountability will be required of health care workers to these customers. In many settings

this will mean that skills training, work rules and advancement will be tied, in part, to the

evaluation of service satisfaction by the customer. This in turn will bring about changes in

the ways jobs are structured, staffed and evaluated. Such changes will require more effective

partnerships between professional groups, unions and organizations delivering care.

F. T E C H N O L O G I C A L A D V A N C E M E N T : C L I N I C A L A N D I N F O R M A T I O N

Unlike past technological advances that affected specific jobs in the manufacturing industry,

recent technological innovations have had an impact on nearly every occupation and industry

in the U.S. economy.55 In the health care industry, advances in information, communications

and biomedical technology have revolutionized health care delivery and made change a

permanent condition.

In addition to affecting the way in which health information is processed, technological changes

greatly affect the allied health workforce. Advances in the clinical laboratory and radiology fields

have created new allied health occupations and altered the skills and competencies required of the

workforce.56 Information and communication technology will likely continue to create new and

alter existing occupations for the health care workforce. These technologies also will influence

health professions education and health care delivery, with an overall emphasis of increasing

efficiency, lowering cost and increasing access and quality in the long-term. Some examples of

these influences are described below.

Information and Communication Technology - Information technology presents tremendous

opportunity for the health care industry. A variety of applications already exists within

health care, ranging from automation of medical records to tracking of financial claims and

clinical outpatient visits. In one year, the health care industry deals with 4.8 billion claims,

418 million outpatient visits and 1.7 billion prescriptions, all of which can be processed

most efficiently with information technology.57

A still more intriguing application is the field of telemedicine — the use of electronic

information and communications technologies to provide and support health care when

35




36 distance separates the participants. Early applications of telemedicine targeted populations

in remote areas where fewer medical practitioners were practicing. Several health care

facilities in California have received funding to develop telemedicine programs to assist

those in remote rural regions. One example is a home health care system that permits nursing

staff to visually assess and interact with patients whom would otherwise be out of reach.58

Medical information technology is increasingly viewed by hospital systems and health

plans as a competitive weapon. Information technology provides the means for

collecting, analyzing and presenting the data by which consumers choose their health

care plan. And as quality becomes a more important factor in purchasing decisions,

systems with advanced data systems will find it easier to prove their value. To note,

executives participating in the poll reported that the health care delivery system has not

quite reached that point yet.

Biomedical Technology - Since the Second World War, the U.S. has been the leader of

investment in basic and applied biomedical research. The extraordinary momentum of related

fields has been fueled predominantly by the National Institutes of Health in the 1960s.

Researchers had unprecedented opportunities to advance the understanding of pathogenesis

and to provide a scientific basis for practical development of tools for prevention, diagnosis and

treatment of major diseases. Today, however, as commercial investment surpasses public

investment, the trend is towards a greater emphasis on the application of technology.

The technological advances that emanated from the basic research have transformed

virtually every discipline within the biomedical sciences. Current areas of emphasis include

high performance computing, molecular and cellular structural biology technologies,

biomedical engineering, noninvasive imaging and spectroscopy, and mathematical

modeling and computer simulations.59 This technology promises not only to become an

enormous economic force in the next century but also to “push the moral, ethical and legal

underpinnings of society in confronting such issues as the beginning of life, the nature of

freewill and freedom, and the relationship of individuals to science and religion.”60

Implications for the Workforce - Technological advances in the health care industry have created

entirely new occupations, especially in allied health, and changed the mix of personnel used

in care delivery. Different studies report the emergence of between 30 and 50 new allied

health occupations since the 1960s because of these technological changes.61 Advances in the

radiology field, for example, have led to the emergence of three new technologist positions:


ultrasound technologist, nuclear medicine technologist and radiation therapy technologist.

In the modern clinical laboratory, new technological skills require health specialists such

as the medical technologist, medical laboratory technician/assistant, histologic technician

and cytotechnologist.

Advanced use of health care information by both practitioner and consumer will be a

core element of the emerging health care system. Likewise, this is only the beginnings of

what the biomedical and technological revolution will bring. While these innovations may

not be developed by the allied and auxiliary worker, they will serve to shape and direct their

work. As many of the allied health care professions and occupations have been created as a

response to technological innovation, it seems likely that future proliferation of all of these

technologies will produce demands for new occupational and training pathways in allied

health. The demands of the system for a more flexible workforce will mean that there will

be pressure to incorporate these skills into core or common competencies across all of the

allied professions.

G . T H E I N D I G E N T, U N I N S U R E D A N D W E L F A R E P O P U L A T I O N S

While the U.S. economy has improved markedly in the 1990s, opposing trends are placing

significant proportions of the workforce population at risk with respect to health care.

One noteworthy shift is the widening gap in the income levels of those who make up the

general workforce. There are also increasing numbers of people without health insurance

even among those employed. Moreover, former welfare recipients who are moving into the

employment sector in greater numbers may not have access to the types of support

mechanisms needed nor the background experience to remain employed. The numbers of

uninsured and welfare recipients are greater in California than the national averages.

These national and state trends are helping create a significant population at risk for factors

such as job displacement, unsustainable income levels and inadequate access to health care

and other services.

While the widening gap in income, increasing rates of uninsurance and welfare reform all

impact the health care environment that health care workers practice within, these trends

may disproportionately affect the allied and particularly the auxiliary health care workforce.

Allied and particularly auxiliary workers are most likely to be at risk for low socioeconomic

status and inadequate health access among health care workers.

37




38 1. WIDENING INCOME GAP

As the nation has experienced changes in the employment sector over the past 30 years,

related changes have occurred in the distribution of income and wealth. This transformation is

most dramatically represented as the shrinking of a broad middle class, with growth in those

parts of society having both more and fewer resources. During the 1980s, these changes were

most dramatic. The Congressional Budget Office (CBO) figures document a 10.5 percent

drop in average after-tax family income for those families in the lowest 10 percent family

income group. At the same time, the figures document a rise of 24.4 percent for families

in the top 10 percent average after-tax family income group. Moreover, for families in the

top 1 percent income group (earning between $174,498 to $303,900 in 1987), there was a 74.2

percent increase in income.62 These shifts relate to dramatic changes and differences in how

the nation’s populations think about and access health care, social services and education.

At one end of the spectrum, families with more resources may find it easier to exit the

traditional public sector for private institutions because of greater ability to pay for these

resources and a perception that quality has eroded. With this exit, there is a splintering of

public support for an entire range of institutions that will profoundly affect their future.

At the lower economic end of the scale, traditional orientations and values for seeking health

care, supporting children in public education and participating in community life may be

threatened. For individuals and families at this end of the spectrum, traditional views may

be replaced as different value systems, the necessity of two-income families, a preponderance of

single parent families, and other non-traditional factors become more common. Not only are

there different attitudes and views, but also different patterns or approaches to institutions

such as health care that may be in stark contrast to those of the higher income population.

For example, a recent study found that overall, Californians over age 40 are more active

consumers of health than people over age 60 in other states. This survey also found that the

percentage of “proactive” residents — those who take an active role in maintaining health —

in California is about eight percentage points above the national rate.63 Another study

found that while the state index falls slightly below the national mean for average length of

stay in hospitals, emergency room visits, physician visits, and nursing home use, California

ranks at or above the national mean with regard to dental visits, surgeries and senior home

care.64 These patterns likely reflect those of the higher income population, and not those at

the lower economic end.


2. THE UNINSURED

In conjunction with the widening income gap, a significant percentage of the population

lacks health insurance. From 1995 to 1996, national data indicate that 16.3 percent of

persons 18 years of age and older were without health insurance, 6.8 percent were

underinsured and 76.9 percent were adequately insured. California has a level of uninsurance

above the national median in all age groups, with 38.7 percent uninsured for 18 to 24 year

olds, 26.3 percent for 25 to 34 year olds, 18.6 percent for 35 to 44 year olds, 14.8 percent

for 45 to 55 year olds and 15.1 percent for 55 to 64 year olds.65 (See Exhibit 7) Furthermore,

a study focusing on California reported more than 7 million of the state’s residents were

lacking medical insurance in 1997. The study found that one out of five Californians worked

for an employer who did not offer health benefits to any employees and concluded that

despite the continued growth in California’s economy in 1997, the number of uninsured

non-elderly is growing at a rate of nearly 50,000 per month.66

This study reported a disturbing increase in the percent uninsured over time. For example,

between 1995 to 1997, there was an increase from 22.7 to 23.8 percent in the rate of

uninsurance in California. In conjunction, Medi-Cal coverage dropped from 42 percent in

1996 to 32 percent in 1997, when the state’s population living in poverty actually increased

5 percent. The authors of the study note that with welfare reform and low unemployment,

newly employed California residents are finding jobs that do not include health benefits.67

Another perspective on health insurance to note is the level of uninsurance for the allied

and auxiliary health care workforce itself. Using 1993 workforce data, a national study noted

39



25.4%

38.7%

16.9%

26.3%

11.9%

18.6%

14.8%

10.1% 10.5%

15.1%

United States

California

18-24 25-34 35-44 45-54 55-64

AGE GROUPS

PE

RC

EN

T OF P

OP

ULATIO

N45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Source: Behavioral Risk Factor Surveillance System, 1995 to 1996.

E X H I B I T 7: Percent of Uninsured Population, United States vs. California, 1996


40 11.7 percent of all health care workers lacked health insurance.68 In a more recent survey

focusing on California, data showed that, for the 5.1 percent of the random sample working

in health care occupations, 76.7 percent reported some level of health insurance and,

therefore, 23.3 percent had no health insurance in 1998.69

In relation to the auxiliary health care workforce for whom a high school level education is

most common, a study on wage earning trends and health insurance status among employed

adults who have a high school level of education or less is of interest.70 These adults comprised

44 percent of the total labor force (22 to 62 years of age) between 1990 and 1995. While this

population’s level of uninsurance has remained fairly constant, from the highest to the lowest

earning group, the data show increasingly higher levels of uninsurance. For example, 40.5

percent of the lowest earning group lacked health insurance in 1995.71 Furthermore, with

recent welfare policy changes, the authors of the study note an additional one to two million

former welfare recipients will enter this part of the workforce.

3. WELFARE REFORM

Nationally, 4.3 million families received welfare benefits in 1996 according to the U.S.

Bureau of Labor Statistics. In the wake of federal welfare reform, approximately 25 percent

or 1.1 million recipients were required to enter the workforce in 1997. While this is less than

one percent of the workforce nationally, California has the second largest number of people

on welfare, behind only New York. Moreover, some allied and auxiliary training programs

are being identified as welfare-to-work programs. For these reasons, this section provides an

overview of welfare reform and presents the challenges and successes of welfare-to-work

programs in health care.

With the pressure to balance the federal budget and employ more people to stimulate the

U.S. economy, the 1996 welfare reform law represents an example of a market-based

approach to a societal need.g While the U.S. has traditionally placed enormous faith in the

ability of large-scale public programs to address social problems in areas such as

employment and education, this faith is now being tested as more market-oriented


g. In 1996, Congress replaced three large-scale public programs, namely Aid to Families with Dependentchildren (AFDC), Job Opportunities and Basic Skills (JOBS), and Emergency Assistance programs with thePersonal Responsibility and Work Opportunity Reconciliation Act (PWORA). This federal block grantprovides cash assistance, employment and training activities to states for the welfare population. Theblock grant called Temporary Assistance to Needy Families (TANF) holds states accountable for designingwelfare mechanisms that require welfare recipients to be working within two years of first receiving benefits.

approaches upholding accountability emerge in education, welfare and health. These

approaches, such as the 1996 welfare reform initiative, look to the consumer to choose

patterns of consumption that will lead to more efficient use of resources.

California’s welfare-to-work program is being planned and implemented through the

coordinated efforts of a number of state and local partners. These include the Employment

Development Department, the Department of Social Services, county welfare departments,

local private industry councils, as well as community-based organizations, educational

organizations and the business community. The California Work Opportunity and

Responsibility to Kids (CalWORKs) program coordinates and implements the federal

welfare reform for the state. In 1998, California received $190 million and will receive

approximately $173 million in 1999. Of these funds, 85 percent will be allocated to the

private industry councils to spend on eligible participants and allowable activities including

job creation through public or private sector wage subsidies, on-the-job training and

contracts for job placement and post-employment services.

Informal discussions with CalWORKs and other organizational leaders involved in welfare

programs indicate that each county in California sets guidelines for the time frame and

focus of welfare job preparation programs, including the work-first or train-first

orientation. From these discussions, it appears that many of the welfare-to-work

educational programs prepare recipients for data-entry, clerical or childcare occupations.

Still, there are some allied health training programs in the educational sector, including

certified nursing assistant (CNA), home health aide (HHA), Emergency Medical

Technician (EMT) and surgery technician training programs.

It may prove problematic to enroll welfare recipients into programs in which training

requirements may not be met in time to meet those requirements of the new welfare

system. For example, some community colleges have considered and/or developed welfare-

to-work training programs in respiratory therapy. However, given the training

requirements — a two-year associates degree — and the welfare students’ requirements,

there do not appear to be successful programs in this area of allied health. Despite these

challenges, there are segments of the health care system, educational institutions and

community-based organizations that have begun to look at ways to participate in these

welfare initiatives, particularly some Certified Nursing Assistant and Home Health Aide

training programs. Motivated by shortages in recruiting and retaining workers for many of

41




42

Rubicon Programs Inc. Welfare-to-Work Training Program

One successful welfare-to-work training program in health care is coordinated by

Rubicon Inc. The community-based agency partnered with Contra Costa College, and

sponsored one of the college’s Certified Nursing Assistant and Home Health Aide

(CNA/HHA) combined training programs. The combined program offers the clinical and

class instruction required by the state of California to certify individuals as CNAs and

HHAs. From Rubicon’s sponsored section, 21 individuals have completed the training and

been placed with the home health agency in Richmond, California.

Rubicon Programs Inc.:

For twenty-five years, Rubicon, a non-profit agency, has provided job training,

employment, housing and counseling services to people who have been homeless, disabled

or poor. The partnership between Contra Costa College and Rubicon is an example of

Rubicon’s outreach to women on AFDC or TANF to support their movement into

employment. Rubicon’s support extends from initial interviews with potential students to

funding support for both the college and the students who enroll. Although the state does

not require graduation from high school or other prerequisites for CNAs or HHAs,

Rubicon screened each student who entered the sponsored section. In addition, Rubicon

arranged for CPR training off-campus and provided the funds for Contra Costa College

to staff the training program. For the students, Rubicon provided funding for tuition,

books, uniforms, malpractice insurance and the fees for the Federal Competency Test

required for CNAs. During the program, students have access to the support services on

the Contra Costa College campus as well.

(continued)


its lowest paid positions, the long-term care sector may lead the health care industry in

experimenting with these initiatives. Profiled here are Rubicon Programs Inc. and the UCSF-

Stanford Health Care Welfare-to-Work Training Programs, two successful welfare-to-work training

programs for jobs in health care.

43



(continued from page 42)

Contra Costa College:

In response to the increased demand for both CNAs and HHAs, Contra Costa College

began offering the new joint program in their Nursing Department. The program consists

of a two-day orientation, a language skills laboratory and the state required theory and

clinical training. The orientation incorporates an introduction to the state regulations,

medical terminology, and procedures such as taking blood pressure and critical thinking

skills. The theory and clinical training includes requirements set by the Department of

Health Services and California Administrative Law Title 22 concerning communication

skills, ethical and legal implications, patient’s rights, basic skills, infection, and death and

dying. In combined programs, the state allows certification for both the CNA and HHA

for students who first complete the CNA training, and then follow this with 20 additional

hours of theory and 20 additional hours of clinical practice for the home health skills.

Contra Costa College has 3 to 4 teachers available to teach the CNA/HHA program.

One instructor is dedicated to theory and the others lead the clinical training, with a teacher-

student ratio of 1 to 15 or lower. The clinical portion occurs in skilled nursing facilities,

either the Doctors Office in Pinole or at Creekside in San Pablo. Given the financial pressures

facing home health agencies, Linda Schweid, the program director, explains “it is just too

difficult for these agencies to provide clinical training opportunities themselves.”

The College initiated a welfare-to-work program by partnering with community agencies

such as Rubicon and the local private industry council that conduct outreach and their

own publicity efforts. Now with the program in place, Contra Costa College lists the program

in the general college schedule and has had enough enrollees to offer the class. According

to Schweid, the teachers get very involved, not only with the curricula, but also with the social

services and support provided to the students. Schweid relates that the pinning ceremony

at the program’s culmination is particularly rewarding for both the students and the

instructors. Schweid stated the College would welcome the opportunity to work with other

sponsors in similar programs given the success with the Rubicon-sponsored section.

Contra Costa College enrolls approximately 45 students in each CNA/HHA program

and usually 25 to 30 students complete the training. The section sponsored by Rubicon

enrolled 22 students, and 21 completed the training. This success follows other Rubicon

(continued)

UCSF-Stanford Health Care Welfare-to-Work Training Program

The outpatient clinics at UCSF-Stanford Health Care are one of four health care

employer sites that were selected for a clerical/administrative assistant training program.

In partnership with the Jewish Vocational Center (JVC) and San Francisco WORKS,

UCSF-Stanford provided the classroom for one 12-week training tailored to the

outpatient setting. JVC provided continued welfare benefits, funding for childcare, as well

as initial recruitment and screening of welfare recipients. UCSF-Stanford participated in

the final interview process which resulted in the selection of 15 trainees from 145

applicants. For the program, 15 outpatient clinics were selected, along with 15 mentors

(one at each site) to work with each of the 15 trainees. UCSF-Stanford worked with JVC to

develop the curriculum that covered administrative duties, reception, computer skills and

accessing medical information. The first two months of training consisted of classroom

instruction and pairing up with mentors at the outpatient clinics. The third month

involved working solely at the sites. Eleven of the 15 trainees successfully completed the

program. The training program benefits the welfare recipients by training job skills as well

as UCSF-Stanford by improving the training model and addressing a high turnover rate

in the clerical and administrative assistant positions.


44 (continued from page 43)

employment training programs, which exceed completion rates by the social services

industry according to Rubicon’s Executive Director, Richard Aubrey. The Contra Costa

College and Rubicon partnership serves as a very successful collaboration for welfare-to-

work models that support movement of the welfare population into allied or auxiliary

health care occupations.


45



Despite challenges with implementation, the welfare reform initiative has demonstrated

some positive outcomes as welfare rolls have declined and many states are meeting the work

requirements stated in the 1996 welfare law. California’s decline in welfare recipients is

unique in that the state has seen a sharper decline among Black recipients than Whites.

There has been a 40 percent decline for Blacks, a 31 percent decline for Whites, and a 22

percent decline in the number of Hispanics formerly on the welfare rolls. 72 Statewide,

California did have fewer than the mandated 25 percent of welfare recipients working in

1997, in part due to the challenge of language barriers. Still, some individual counties in

the state, such as Alameda County, are well above this level. This county reported that 70

percent of two-parent families who were receiving welfare were working in 1997. Certainly,

more time is needed to evaluate the effectiveness of welfare reform, and the current racial

imbalance of the population remaining on welfare is disturbing. The challenges of this

population will need to be met in order for welfare reform to be successful and to address

the risk this population faces.


Many of the auxiliary and some of the allied health jobs described in this report exist as

entry-level positions at the lower end of the wage and benefit scale. As such, these workers

face many of the same challenges that other workers in similar places in the labor force must

confront. These include making ends meet with a livable wage, basic health insurance and,

for some, the challenge of moving from welfare to employment. Health care will find it

difficult to sustain a caring and quality environment if it leaves significant portions of its

population at risk.


46

In addition to the seven major forces affecting the dynamic health care system in California,

it is important to understand the specific care delivery settings in which allied and auxiliary

workers are employed. These settings face parallel forces and challenges. The settings

selected for this section — acute care hospitals, outpatient medical groups, home health

agencies and long-term care facilities employ a majority of the allied and auxiliary workforce.

For example, in 1995, 36 percent of allied health providers were concentrated within

hospitals, 17 percent in physician offices and another 18 percent in nursing facilities.h

To include the laboratory technologists and assistants providing testing services to these four

care delivery settings, the reference clinical laboratory setting is also included. Within and

across these five settings, the allied and auxiliary workforce dynamics can be viewed.

In this section, definitions and demographics of the five care delivery settings are

presented based on the literature and secondary data sources. In addition, qualitative

information obtained from interviews and primary data collection is offered. The

descriptions of the five care delivery settings provide the context to discuss the current

workforce demographics (presented in Section IV) as well as the changing roles and

reengineering trends this workforce is facing (presented in Section V).

A. H O S P I T A L C A R E

Hospitals provide inpatient care including medical services, diagnosis, treatment and continuous nursing services;

patients generally stay at least overnight. Acute care provided ranges from medical/surgical, labor and delivery, to

specialized services such as burn and trauma care. Hospitals also provide administrative services as well as ancillary or

environmental services that are related to the facility and overnight stay component of hospital services. There are four types

of hospitals: general acute care, specialty acute care, children’s hospitals and psychiatric hospitals. Each type of hospital can

be long- or short-term depending on the individual hospital’s average length of stay. In consideration of the services provided

by the allied and auxiliary health care workforce in hospitals, this section focuses on general, acute care hospitals.


C A R E D E L I V E RY S E T T I NG SS E C T I O N III

h. Data according to the California Employment Development Department (EDD), Labor MarketInformation Division.

Demographics - In the 1996-97 report period, there were 513 hospitals of which 456 were

general acute care hospitals.73 The 456 general hospitals had a total number of 79,639

staffed beds. Exhibit 8 indicates the distribution of hospital beds per 1,000 residents across

California counties. To note, although Los Angeles County has the highest number of

hospital facilities and beds (with a total of 129 or 28.3 percent of all general hospitals and

32.1 percent of the total number of staffed beds), Sierra County has the highest ratio of

hospital beds per 1,000 population.

According to 1997 OSHPD data,i 32.6 percent of all California hospitals are for-profit

institutions, 48.5 percent are non-profit, and 18.9 percent are government hospitals.

(See Exhibit 9) Hospital care is most often measured by inpatient days, or length of stay, and the

number of hospital discharges. In California, the average length of stay was 4.8 days, excluding

long-term care, and there were 2,811,501 discharges during the 1996-97 report period.

As noted in the Consolidation in a Managed Care System section of this report

(see Section II), over time there has been consolidation in the industry and thus fewer

hospitals and shorter average lengths of stay. For example, during the 1993-94 report

period, the average length of stay for the state was 5.3 days. In relation to the most recent

data indicating 4.8 days, this represents a decrease of 10.4 percent for the average

length of stay in California hospitals in just three years. Furthermore, the total number

of inpatient days decreased from almost 17 million in 1993 to less than 16.2 million in

1997, and during the same period, outpatient hospital visits increased by approximately 6

million visits annually.74 In addition, in recent years, hospital operating expenses have

remained fairly flat. In California between the 1993-94 and 1996-97 report periods,

total operating expenses for comparable hospitals rose only 3.3 percent.

Workforce - According to the aggregate hospital financial data summary from OSHPD,

nurses constitute 36.3 percent of the workforce in California hospitals. Physicians and

administration/management make up part of the remaining 63.7 percent of hospital

employees, but there are many important allied and auxiliary health care personnel in the

hospital setting.

47



i. The aggregate hospital financial data summary from OSHPD presents data for 472 comparable hospitalsin California (excluding Kaiser hospitals and non-comparable hospitals such as those that focus onlong-term care).


48


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data not Available (1)

O.50 to 1.49 (15)

1.50 to 2.99 (29)

3.00 to 6.49 (11)

6.50 to 11.80 (2)

Source: Office of Statwide Health Planning and Development (OSHPD): Hospital Annual Financial Data, 1997 ( www.oshpd.cahwnet.gov);

1998 Population Estimates, MapInfo Corporation

E X H I B I T 8: Hospital Short-term Beds in California per 1,000 Residents by County 1997–98

The allied and auxiliary workforce in

hospitals includes professionals (such as

imaging and clinical laboratory technol-

ogists and rehabilitation therapists),

technicians/specialists (such as rehabil-

itation assistants and aides, medical

record technicians and imaging

personnel), certified and uncertified

nursing assistants, clerical personnel,

and environmental, support services

personnel. Most of the allied and

auxiliary personnel are categorized as

clinical personnel; however, medical record administrators are considered non-

clinical professionals, and so are clerical and support services personnel who are not

crosstrained in nursing aide roles.

The roles and skills of allied and auxiliary health care providers are changing

significantly in the hospital setting. With crosstraining and new orientations for

delivering care in hospitals, there is greater reliance on teams rather than individual

practitioners providing care. For allied and auxiliary workers, this means new service

roles as well as more interaction among all kinds of providers. New titles have emerged in

hospital settings, from the physician-level hospitalist, to technologists crosstrained in

unique combinations of imaging modalities, to patient care and patient support assistants

in nursing units. From the Project’s qualitative interviews, the challenges hospitals face

in recruiting and retaining their allied and auxiliary workforce are described in Comments

from Hospital Human Resources Directors.

While many of these personnel are employed by the hospital, some provide services

contracted out by the hospitals, such as transcriptionists, physical therapists, and support

services personnel. Although fewer in number, there are also personnel employed on a

temporary basis. For the allied and auxiliary workforce, the interviews with hospital

employers indicated less than five percent of employees are temporary; however, hospitals

do employ per diem workers who work less than full-time, receive a pay differential and are

not eligible for benefits. This is confirmed with the OSHPD data, where 2.2 percent of the

49



Government18.9%

Non-Profit48.5%

For-Profit32.6%

Source: Office of Statewide Helath Planning and Development (OSHPD).

Aggregate Hospital Financial Data Summary. Report Period Ending 1996–97

E X H I B I T 9:Profit Statusof Hospitals inCalifornia,1996–97


50 Comments from Hospital Human Resources Directors

“Because we are a rural facility it is difficult to maintain competitive salaries with urban and

cities within 20 to 25 miles.”

“Productivity standards increasing due to cost containment, acuity of patients has increased

which requires increased skills/experience for all classification [of workers].”

“Cost of bay area housing, competition and non-hospital/for-profit employers, over-

regulation within hospital setting, limited outreach and training money.”

“Fewer applicants to choose from; less prepared applicants.”

“If unemployment remains low, the challenge will be to find competent, motivated and

educated individuals to fill any of our openings.”

“Difficult to recruit individuals with the skill level required in a teaching hospital. Many

competitors with less demanding environments.”

“The hospital decision to either close or rebuild is slowing down...recruitment. Low pay

rates compared to market. Occupational and Physical therapists have very little freedom to

practice outside specific organizational guidelines, which discourages hiring. The money

that the organization has lost over the past few years has scared some applicants as to the

financial viability...”

“Unstable work environment related to reengineering. Limited flexibility in managing work

schedules. Unable to offer incentives to temporary employees.”


total number of productive hospital full-time equivalents (FTEs) was reported as the

number of nursing registry and other temporary FTEs. Further discussion of these changing

roles, contracting services and temporary employees is provided in Section VA of the report

Trends - Increasingly restrictive health care reimbursement policies over the past two decades

have hit the hospital setting especially hard. With medical payment reform in the early 1980s,

state legislation removed a significant number of Medi-Cal recipients from eligibility,

resulting in the transfer of these patients to county hospitals. To promote competition and

contain cost, a 1982 state law allowed payers to selectively contract for hospital services. In

addition to HMOs, preferred provider organizations (PPOs) were increasingly using selective

contracting. PPOs coordinate a large number of buyers giving them market power that they

use to obtain discounts for care. Hospitals can also compete for patients and increase revenue

by offering a particular set of health plans, locations and quality of care.75 These activities have

led to increased competition between the public and private sectors of health care.

In conjunction with these activities, the Medicare Prospective Payment System (PPS) was

implemented in 1983, shifting cost-based reimbursement to a diagnosis-related group (or other

per case payment system) form of payment which added to the reduction of reimbursement levels

that competition was creating.76 One result of this implementation was an incentive for hospitals

to shorten inpatient stays and transfer patients to either long-term care facilities or home health

agencies. While this is now changing, in the 1980s, these settings of health care were not yet

implementing the PPS and, therefore, hospitals could reduce costs by transferring patients.

In addition to lower levels of reimbursement, there was also an increase in the amount of

uncompensated care delivered by hospitals between 1981 and 1986.77 The author of one study

that analyzed OSHPD data reported that $789.7 million was spent on uncompensated care in

1986, an increase from $530.9 million in 1981 after adjusting for inflation. This growth

occurred particularly in government, non-teaching hospitals. With the increase in the amount

of non-revenue producing care and the decrease in reimbursement levels, both lowering

hospital revenues, the pressure on hospitals to decrease cost is made more serious, particularly

in government hospitals.

There has also been significant regulatory activity that has affected hospitals at the facility

and workforce levels, including regulations established in state code Title 22. This state code

establishes minimum standards of care and minimum numbers of practitioners to provide

this care. Furthermore, in addition to state law, there are independent, private entities such

as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) that set

quality standards for health care providers. Though not required by law, accreditation by the

JCAHO is recognized nationally to set performance expectations and evaluate quality of

services. To earn and maintain accreditation, an organization undergoes on-site surveys by

the Joint Commission at least every three years. The Joint Commission began early in this

century evaluating hospital services, and now extends its programs across health care delivery

settings and health networks.78 Other independent organizations include the National

Committee for Quality Assurance which measures quality outcomes and patient satisfaction

levels for health care organizations.

Workforce Implications - Many of these trends affect hospitals’ budgets, and since labor comprises

the largest component in the budget, hospitals face pressures to adopt strategies to reduce staff,

51




52 increase staff productivity and change the skill mix of labor in order to contain cost. However,

studies show mixed evidence that California hospitals have responded to increasing levels of

competition by hiring fewer hospital personnel. According to one study, there was a small

reduction overall in full-time equivalent (FTE) personnel per adjusted patient day between 1981

and 1993.79 However, there was an increase in the non-clinical FTE personnel in California

during these years. On a national level, there was an increase in both the clinical and non-

clinical FTE personnel, and an 11.3 percent increase in FTEs overall during the same years.

Another study, which examined more detailed personnel data from OSHPD for the years 1982

to 1994, reported that the 326 California short-term general hospitals with complete data

showed an increase in employment. In fact, non-clinical personnel increased 28.0 percent

during these years. Still, the indication that employment growth is seen more in the non-clinical

professions suggests that dislocation of clinical personnel workers, including allied and auxiliary

workers, remains an important issue for this setting.

Other cost reduction strategies by hospitals include shifting care to ambulatory settings,

restructuring the skill mix and tasks of inpatient care providers, and contracting out

services. Many hospitals are implementing patient focused care systems that shift care to

lower, qualified providers. During the Project interviews, smaller, rural hospitals tended to

describe these industry pressures as “the way it has always been.” Thus, the structure of jobs

in these hospitals may have always involved multiskilling, working in multiple functions

and/or settings, or contracting out services because they simply do not have the volume of

care to justify permanent, full-time positions and training.

Collectively, regulations and quality standards affect hospitals and their workforce by

requiring time and resources to document and demonstrate training, education, quality

systems and other factors of health care that contribute to the quality of health care delivery

organizations, particularly hospitals.

B. A M B U L A T O R Y C A R E

Medical offices providing ambulatory or outpatient care figure prominently in the emerging health care system as

hospitals shorten lengths of stay and technological advances allow more procedures to be performed on an outpatient

basis. Ambulatory care refers to a range of services provided to patients who are not hospitalized and can be delivered

in a variety of settings: free-standing ambulatory care centers, urgent-care facilities, community health clinics, blood

centers, outpatient surgery centers and physician offices. The types of care provided in ambulatory settings vary dramatically.


First, there are routine procedures (including routine, preventative care, less complicated surgeries, and routine imaging

procedures) that are more predictable in terms of provider time, cost and higher patient expectation. There are also

more complex, less predictable procedures that may require more expensive or complicated technologies.

Demographics - While there are a broad range of services and entities in ambulatory care, the

American Medical Association (AMA) defines an ambulatory medical group as a provider of

health care services by three or more physicians who are formally organized as a legal entity

in which business and clinical facilities, records and personnel are shared. Furthermore,

new variations of medical offices are emerging and being defined with varying kinds of

ownership, relationships with health plans, managed care plans, and hospitals that they

contract with, as well as levels of managing the risk associated with health care costs.

Therefore, physician groups exist along a spectrum with varying levels of organization and

financial independence, and individual physicians can be owners or employees of these

groups. At one end of the spectrum, ambulatory care exists as the solo or small group

practice, where physicians own and direct outpatient care services and contract directly with

managed care or other health plans. More organized are Independent Practice Associations

(IPAs). In these arrangements, a network of physicians participates with an intermediary

association that contracts with managed care plans and in turn, the association manages all

or part of the business risk.

IPAs are becoming more dominant in California, as they allow physicians to maintain

more responsibility and ownership of their practices. At the other end of the spectrum is the

completely integrated medical group in which physicians contract with health plans and/or

health purchasers who fully own the business. It is important to note that individual

physicians can provide care under one or more of these medical group models. Each type of

medical group frequently contracts with multiple health care plans and adheres to either

individual or group standard clinical practices. Moreover, medical group sizes range from

three physicians to 100 or more. The specialty composition from family/general practice to

single specialty to multi-specialty groups varies as well.

On a national level, the number of medical groups has been increasing. In 1984, there were

15,485 medical groups in the U.S., and in 1996 there were 19,820, a 28.0 percent increase.j

53



j. As presented in the 1999 Edition of the American Medical Association Group Practices in the U.S. report.


54 Between the same years in California, the

number of medical groups remained constant

with 1,645 in 1984 and 1,694 in 1996. Of the

1,694 medical groups in California in 1996,

there was an average of 11 physicians per group.80

However, 47.9 percent of the medical groups

in California had 3 to 4 physicians. See Exhibit

10 for the distribution of medical groups in

California by group size. Also to note, California

has the greatest number of medical groups of

any state in the nation.

A Business Outlook - Regardless of size and degree

of separation between clinical care and the health care business, all types of medical groups

described above exist in the transforming health care industry, and, thus, they all experience

market pressures. Various personnel in these medical groups take on the health care business

role, ranging from medically trained physicians to business trained individuals. Yet, the business

responses to market pressures by these various personnel may be quite similar. For example, in

terms of physician employment and payment policies, a recent study found that physician-run

IPAs in California are similar to “business-run” managed care organizations.81 Also, IPAs use

capitation, where payment is based on the number of patients treated, a payment method similar

to the HMO networks. The growth of physician practice management (PPM) firms also reflects

the response to market pressures for medical groups. PPM firms are recognizing the need for

financial resources to support medical group businesses.82 Therefore, while there are many types

and organizational structures to medical groups, they may function in similar ways.

As for ownership of medical groups at the national level, 77.9 percent of the groups were

owned by a professional corporation or association (solely owned by physicians), 2.0

percent were for-profit, 13.8 percent were part of partnerships, and 3.9 percent were

owned by non-profit foundations in 1995. Furthermore, 87.6 percent of the groups have

contract relationships with one or more HMOs and 91.7 percent have contracts with

preferred provider organizations. In terms of service to Medicare and Medicaid patients,

29.1 percent and 12.1 percent of the medical group patients are Medicare and Medicaid

patients respectively.83


Source: American Medical Association Medical Group Practices in the U.S.

1999 Edition.

E X H I B I T 10:Distribution of

CaliforniaMedical Groupsby Group Size,

1996

10 to 4918.7%

3 to 447.9%

50 or more2.3%

5 to 931.1%

Group Size (Number of Physicians)

Allied Health Personnel - Allied personnel who work across health care settings, such as

rehabilitation therapists, assistants and aides are employed in the ambulatory care setting.

There are also clerical positions in physician offices, including medical billing personnel,

medical secretaries and medical records personnel. In medical records, there is a new

diagnostic and procedural coding certification category for outpatient procedures.

This certified coding specialist (physician-based) has been implemented by some of the

health information technology programs. Physician offices may also have clinical laboratory

and/or radiology departments affiliated with the practice, and allied personnel including

x-ray technicians and laboratory assistants staff these functions.

Medical assistants (MAs) and medical office administrators and managers provide a variety

of services in ambulatory care. While there are formal allied health programs for MAs across

the state, their responsibilities in medical groups range widely from “front office” clerical,

reception and billing to “back office” clinical and support care for nurses and physicians.

Medical office managers and administrators also vary in their duties and even more so in the

training they receive. These personnel sometimes have clinical training as a nurse or MA,

while others have no standard training and learn office management roles on the job.

Trends and Workforce Implications - Many trends mentioned above are affecting the ambulatory

care setting. These trends include: 1) an increase in the number of outpatient procedures

and patients; 2) the linkage of outpatient services to hospital, long-term and home health

care services; 3) the introduction of prospective payment systems and other responses

stemming from the financial pressure exerted on this setting; and 4) the change in how the

allied health care workforce provides service in this setting. First, the increasing use of

ambulatory care services represents the only growth area among current hospital-based

services.84 In particular, there has been an increase in ambulatory surgery centers and

radiology services. On a national level, 54 percent of surgeries performed in hospitals in

1992 were performed on an ambulatory basis, an increase from 21 percent in the previous

year.85 According to OSHPD data, there were 33,156,006 outpatient visits in the 1993-94

report period and 38,947,936 in the 1996-97 report period. This is an increase of 17.5

percent in California hospitals.

As prospective payment systems affect each of the care delivery settings, ambulatory care

facilities and medical groups will also be affected. These payment systems are particularly

challenging in ambulatory care where the type of patients and care varies more than in other

55




56 care delivery settings. Although it is not used extensively, the Ambulatory Patient Group

(APG) is a patient classification system that has been developed as the basis of a prospective

payment system for a facility’s outpatient care cost.86 APGs are the outpatient equivalent of

diagnostic-related groups (DRGs) using the outpatient clinic visit as the base unit of

payment. They are used not only as a cost planning method but also to define nursing

activities and time for patients and/or diagnoses.

Perhaps the most significant trend in the ambulatory care setting is the changing service

role for allied and auxiliary workers. Project interviews found that, with more integrated

systems of health care, some allied professionals are working both in inpatient as well as the

outpatient settings. Furthermore, each setting requires distinct skills and work attitudes. For

example, this means physical therapists can serve as a primary provider and as a

complementary or supportive provider who is part of an interdisciplinary team. Physical

therapists also can provide long-term rehabilitation assessments and care, as well as short

term types of triage or rehabilitation plans.

As ambulatory care centers take on team-based, community care approaches, all allied

health care providers in this setting may take on new roles and responsibilities. Not only will

physical therapists take on more primary roles, other allied health care providers such as

MAs will take on new roles that require more critical thinking, communication with both

patients and other providers, and a broader perspective of patient care that includes

prevention-related services. And finally, given the increasing volume of services patients

receive in the ambulatory care setting, there are more and new types of personnel in

outpatient settings. These include: management personnel to support the new business

structures in medical groups; information systems personnel; health educators to provide

preventative services; and “telephone” personnel to handle both clinical care tasks as well as

administrative or scheduling tasks which include linking ambulatory services with hospital

and home health services.

C. H O M E H E A LT H C A R E

Prior to recent changes in the Medicare payment system for home health, this industry experienced rapid growth.

This expansion was stimulated by attempts to reduce costs, shorten lengths of stay in hospitals, and advance

technologies that have allowed for many procedures that were formerly available in the hospital to be performed in

patients’ homes. However, increased government scrutiny and changes in the payment structure have recently


challenged the home health industry’s growth. The following

section describes the number, type and variety of home

health care agencies and also examines the growth and

present challenges that the industry faces.

Demographics - A home health agency is a

public agency or private organization

including but not limited to, any partnership,

corporation, or political subdivision of the

state or other governmental agency within

the state which provides skilled nursing

services to persons in their temporary or

permanent place of residence.87 Home health services are defined as those services that

are provided to a patient in a place of residence or used at the patient’s home.88 Home

health services can be as fundamental as assistance with activities of daily living (ADLs),

including dressing, bathing and feeding oneself. Home health agencies may also provide

more complex medical services such as chemotherapy treatment for cancer patients or

home renal dialysis treatments.89 All home health services, except for non-skilled nursing

services such as homemaking or assistance with ADLs, must be provided under the

supervision of a physician.

In addition to the certified home health agency, hospice programs also provide home health

services. Hospice programs are defined as services provided to a dying person in the final stages of

life. In 1995, of the 1,116 home health agencies in California reporting to the Office of Statewide

Planning and Development (OSHPD), 135 of these organizations provided hospice programs.

The majority of home health care agencies in California, approximately 68 percent, are

proprietary. (See Exhibit 11) According to OSHPD, in 1995, of the 1,116 facilities reporting

in California, 756 were for profit, 312 were non-profit and 48 were government

agencies. Therefore, 32 percent of home health agencies in California are non-profit or

government institutions.

Financing in Flux - Medicare is the single largest payer for home health care services. In 1996, 3.8

million Medicare beneficiaries nationally used Medicare to cover home-care services. Other public

payers of home-care services include Medicaid, the Older Americans Act, Title XX Block Grants,

57



Government4%

Non-Profit28%

For-Profit68%

Source: Office of Statewide Health Planning and Development Department.

Licensed Services and Utilization Data of Licensed Home Health Agencies.

Report Period: January 1, 1995 to December 31, 1995, p.D2.

E X H I B I T 11:Profit Statusof Home HealthAgencies inCalifornia, 1995


58

the Department of Veterans, Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS) and local community grants programs. Private insurance, managed care

organizations and private out-of-pocket payments are also used to cover the costs of home health

services. According to Exhibit 12, government expenditures related to home-care per visit costs are

expected to increase by 54.1 percent between 1993 and 2005. However, the implementation of the

Interim Payment System may decrease these expenses due to a decrease in the number of visits.

Until recently, Medicare and Medi-Cal patients were reimbursed the full amount of home

health care costs, within certain limits. However, the Balanced Budget Act of 1997 established a

new reimbursement system for Medicare home health services for cost reporting periods

beginning on or after October 1, 1997. An Interim Payment System (IPS) has been developed

until the prospective payment system (PPS) is initiated with cost reporting periods beginning on

or after October 1, 2000. Based on information from the National Association of Home Care,

under the IPS, home health agencies will be reimbursed the lowest of: (1) their actual, allowable

costs; (2) the aggregate reduced per visit cost limits; or (3) a new aggregate per beneficiary limit.

The per-beneficiary limit is based on a cost per patient including non-routine medical supplies

during federal fiscal year 1994.

These changes will have two significant impacts on the health care industry. First, hospitals with

an affiliated home health agency will refer patients solely to this institution. Interviews with home

health agencies have indicated that referrals to freestanding home health agencies will be

significantly reduced. The provisions of the Balanced Budget Act also require many agencies to

significantly reduce their average cost per patient, which may result in a reduction in home health

services provided to a patient.


E X H I B I T 12: Medicare Home Health Visits and Incurred Expenditures

YEAR VISITS COST INCURRED COST PER VISIT(thousands) (millions)

1990 37,906 $2,104 $55.51

1993 169,377 10,269 60.63

1996 278,761 18,141 65.08

PROJECTED

1999 340,357 25,097 73.74

2002 381,746 31,704 83.05

2005 412,583 38,549 93.43

Original Source: Health Care Financing Administration Press Office, 1997 Reproduced from: O’Neil E, Coffman J. Strategies for the Future of Nursing: Changing Roles,

Responsibilities and Employment Patterns of Registered Nurses. San Francisco, Ca: Jossey-Bass Publishers., 1998. p. 155.

Industry Growth - As of October 1994, the home health care industry was the fastest growing

portion of the health care industry. Between 1988 and 1993, employment in home-care

increased annually by 16.4 percent, significantly higher than the 4.3 percent annual growth

rate for total health services employment in the U.S. In California, between 1990 and 1995,

the number of home health agencies increased by 134.3 percent. (See Exhibit 13)

Several factors encouraged the rapid rate of increase in the home health care industry. The

use of the prospective payment system in the acute hospital sector had a significant impact

on the number of referrals to home health care agencies. Inherent in a PPS for acute care

hospitals is the incentive to discharge patients as soon as medically possible. Therefore by

transferring patients over to the home-care unit, hospitals were able to increase profit

margins by shifting overhead costs to a cost reimbursement home care program and

therefore decrease direct inpatient costs.90

In addition, expansion in the home-care industry occurred due to technological advances

in the medical field. Technological advances have allowed procedures that were once

performed only on an inpatient basis to be shifted to a home health agency. For example,

cancer patients can now receive chemotherapy treatment at home through computerized

pumps that deliver medications at precise dose frequencies and intensities, and heart

patients can be monitored and treated at home by hospital-based teams using fiber-optic

telecommunications.91 In some instances, equipment has been adapted especially for home-

care services, such as: blood glucose monitoring devices for the diabetic; computerized

equipment for the disabled; mini-intensive care units with ventilators and central venous

lines; and mobile laboratories that can travel to a patient’s home.92

59



E X H I B I T 13: Statewide Trends in Home Health Agency Utilization, 1990 to 1995

YEAR PATIENTS VISITS HHAS REPORTING VISITS VISITS/PATIENT

1995 691,788 16,701,687 1,010 24.1

1994 621,547 14,299,856 911 23.0

1993 543,281 11,595,467 792 21.3

1992 461,161 9,098,070 595 19.7

1991 436,004 7,369,340 535 16.9

1990 401,400 6,006,969 431 15.0

Source: Office of Statewide Health Planning and Development Department. Licensed Services and Utilization Data of Licensed Home Health Agencies. Report Period:

January 1, 1995 to December 31, 1995. p.1.


60

The reduced cost associated with providing services in a patient’s home instead of in a

hospital or long-term care facility encouraged home care as an alternative. Government,

hospitals and other providers looking to control costs with more efficient ways of delivering

care are looking to home-care to meet this need.

Home health services are provided to persons of all ages, however, the majority of services

are provided to persons over the age of 60. For example, in California in 1995, persons age

71 and over received 51 percent of the home health services. (See Exhibit 14) Therefore, given

that the number of persons over the age of 65 is expected to increase there will be an increase

in the need for home-care services.

Constraints - The introduction of the interim payment system, preparation for the

prospective payment system and increased government scrutiny of the home health care

industry has placed new restrictions on the home health industry. Between January and

September 1998, the Department of Health Services reported that approximately 130 licensed

home health agencies had closed in California. Although these closures have not been linked

directly to the implementation of IPS, it is likely that the new reimbursement system has had

a significant impact on closures. In fact, all of the home health agencies interviewed for the

Project reported a decrease in the number of visits. Some reported dramatic reductions in

monthly visits, and almost all were forced to downsize their staff and shift at least a portion

of workers to a per diem basis. In addition, respondents to the inquiry of executive leaders

in California health care institutions indicated that there was a decline in home health

services that has accompanied the dramatic changes in reimbursement procedures.


8%

3%

5%6% 6% 7%

26%

15%

20%

5%

0-10 11 to 20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91+

AGE GROUPS

PE

RC

EN

T OF P

OP

ULATIO

N30%

25%

20%

15%

10%

5%

0%

Source: National Association for Home Care. Basic Statistics about Home Care, 1995.

E X H I B I T 14: Percent of Patient Population Served by Home Health Care Agencies in California by Age Group, 1995

There are several factors that influence the effect that these changes have on a particular

agency. The Project interviews indicated that agencies with a lower per beneficiary cap tended

to have a more difficult transition. Since the annual per beneficiary cap is based on 1994

financial reports, those agencies which had made an effort to reduce costs received a lower cap

therefore penalizing them for their efforts. The literature also suggests that agencies that will

be most affected by IPS will include: 1) those that have had an increase in severity in their case

mix since 1994, which would require either more visits or a higher use of nurse or therapy

services; 2) small agencies servicing large numbers of high-use patients that cannot balance

their use with increases in patient admissions who require less services; 3) rural agencies where

alternative sources of care are less likely to be available; 4) agencies that have added services since

1994, the cost of which would not have been included in the per beneficiary limit calculation;

and 5) new providers and agencies that are the result of mergers and acquisitions.93

The home health agencies interviewed were impacted by the changes imposed under IPS

in a number of different ways. These impacts included a decrease in visits, reduction in staff,

and an inability to accept patients with a higher acuity of care or that needed daily

treatments. For example, some agencies reported that visits had decreased by a half to a

third. Many agencies shifted employees to a per diem status in order to reduce costs.

Home health aide visits in particular have significantly decreased as a result of the need

under IPS to decrease non-medically necessary visits. In order to stay under the per

beneficiary cap, agencies have had to reduce the visits for services such as bathing, cooking,

light housekeeping and shopping that were typically provided by home health aides.

Not only will IPS have a significant impact on staff at home health agencies but beneficiaries

are expected to be dramatically affected by these changes. Persons with high utilization of

home health services will be most severely affected by these changes. The highest users of

home health care — the 10 percent with 200 or more visits per year who accounted for 43

percent of Medicare’s home health visits in 1994 — also accounted for 60 percent of the

growth in home health spending over the 1991-94 period.94 High users of home health care

typically include not only the elderly but also persons with poor or fair health, low income

and/or long-term care needs. At least 9 percent of high users of home care have limitations

in activities of daily living, and 79 percent have limitations in three or more ADLs.95

Many have argued that IPS has significantly decreased access to home care for people with chronic

conditions, such as multiple sclerosis, chronic kidney failure, Parkinson’s disease and diabetes.

61




62 Patients with chronic illnesses typically require daily treatments and, thus, are likely to be

affected as home health tries to adjust to the recent changes.96 While no interview respondents

indicated that they were not providing care to persons with chronic illnesses, several interviewees

noted that it was a financial burden to accept patients that required daily treatments and that

the Medicare requirements have decreased their ability to provide quality care to such patients.

The interim payment system previously outlined was created to transition agencies into the

prospective payment system (PPS). The PPS must be designed and at this time Medicare is

intending to implement this system for cost-reporting periods beginning on or after

October 1, 2000. Agencies interviewed were unable to provide information regarding the

impending implementation of PPS and most were not aware of the details of the system.

Representatives from the California Association for Health Services at Home (CAHSAH)

indicated that the new payment system will be a 60-day per episode of care system paid by

prospective payment based on the patient’s case mix category. Under PPS, an additional 15

percent reduction in Medicare payment is also expected.

Based on data provided from per-episode PPS demonstration agencies, home health agencies

will continue to need to reduce visits and costs under PPS and will most likely continue to see

decreases in revenue. This data suggests that the treatment agencies provided 17 percent fewer

visits than the control group, which continued a cost-based reimbursement. Though the

differences were not statistically significant, some of the trends determined from these

demonstration projects were that for-profit agencies tended to reduce visits more than non-

profit agencies and hospital-based agencies reduced visits more than freestanding agencies.

Some of the strategies for adjusting to PPS included an increase in education for patients and

care providers so that they can more quickly become self-reliant; reducing multiple visits by

different service providers; use of specialists to speed healing; and standardization of care by

creating care maps, care profiles, protocols or critical pathways for patients with select diagnosis.97

In addition to IPS and PPS, increased government scrutiny of the home health care industry has

led to a tightening of regulations for this industry. Government scrutiny occurred in large part due

to the rapid and uncontrolled growth of the home health care market. Medicare home health

services have recently been the subject of numerous investigations and congressional hearings.

These hearings concluded that 25 to 40 percent of payments were made for inappropriate or

fraudulent claims.98 Heightened awareness is expected to have a significant impact on future

regulations and standards of operation for home health care agencies nationally and in California.


The increase in government scrutiny, with

its requirements to collect outcomes data, has

added both a financial and time burden for

home health agencies. The introduction of the

Outcome and Assessment Information Set

(OASIS) has presented a challenge to many

home health agencies. OASIS consists of 92

data elements, and must be completed upon

admission, entrance to an inpatient facility,

Medicare re-evaluation every 57 to 62 days,

resumption of care following discharge from

an inpatient facility and discharge. This procedure has been a significant burden to many of

the agencies interviewed. OASIS must be electronically entered into the software within 7

days of the events outlined above and must be reported every month. Some agencies reported

that the procedure is not only time-consuming, but it has been a great expense to purchase

the computer equipment necessary to complete the survey. The Health Care Financing

Administration (HCFA) requires OASIS data to be collected for all patients regardless of payer

source. For example, a patient who is receiving non-physician ordered home health aide services

paid privately by the client, requires the same OASIS data to be collected by a RN at a significant

cost to the agency. In addition to being time consuming for home health staff, one interview

respondent noted that many patients felt that the survey was very intrusive.

Workforce Issues - In the early part of the 1990s, employment in home health care rapidly

expanded. However, given the recent changes with IPS and increased government scrutiny,

continued growth is uncertain. In 1995, experts predicted that an increase of more than

500,000 jobs, or a 128 percent increase, between 1992 and 2005.99 Prior to the recent

changes in the home health industry, agencies were expected to hire large numbers of lower-

paid personnel (including LVNs, aides and assistants) to fill their personnel needs.100

However, interview respondents indicated that due to uncertainty and financial contraints,

they have been unable to hire new staff and were in fact downsizing and transferring

full-time staff to per diem work.

Home health aides provided 31 percent of the visits to patients in California in 1995 101

(See Exhibit 15) and constituted 31 percent of the home health care workforce nationally

63



RN44%

PHN3%

Home Health Aide31%

LVN7%

MSW2%

Occupational Therapist 2%

Speech Pathologist, Nutritionist, Physician,

Spiritual / Pastor and other 0%

Physical Therapist11%

Source: National Association for Home Care. Basic Statistics

about Home Care, 1995.

E X H I B I T 15:Percent of PatientVisits Made byParticular StaffMembers inHome HealthAgencies inCalifornia,1995


64

in 1993. (See Exhibit 16) While HHAs were previously listed as one of the fastest growing

health occupations, many of the home health survey respondents noted an oversupply of

home health aides as a result of the introduction of IPS. Some noted that there has been an

increase in training programs for HHAs, yet job opportunities have decreased. A few

agencies noted that they have had people contact them for employment as HHAs and/or have

lists of people to call in the event that there is an opening.

Due to technological advances and earlier hospital and long-term care discharges (causing

home health agencies to take on patients with a higher degree of medical instability), home

health agencies require a staff that is more highly trained and that can perform more

complex procedures. Home health agencies are also providing more specialized services.

According to Modern HealthCare’s 1996 portrait of the home-care industry, the ten most

frequently offered specialty home-care services include high-risk pregnancy, psychiatric,

cardiac, pediatric, AIDS, cancer and pain management. (See Exhibit 17) These trends explain

the reduction in the rate of increase for home health aides described in Exhibit 16.

Home health care workers, unless employed in a government or hospital-based agency,

receive fewer benefits than do workers in other settings interviewed. Especially since the

advent of IPS, most respondents reported that they have decreased their benefits and since

they are now employing more workers on a per-diem basis, some have eliminated benefits

all together. Aside from one county-run home health agency, all respondents noted that

their employees were not unionized, therefore, this has not been an impediment to

reducing employee benefits.

One of the challenges for home health care agencies is caring for a very diverse patient

population that expects similar diversity of staff to provide these services. The cultural


E X H I B I T 16: Home Health Care Employment by Selected Occupations, 1990 and 1993

OCCUPATION 1990 1993

Physicians and Surgeons .07 % –

Respiratory therapists .13 % .15 %

Occupational therapists .55 % .65 %

Physical therapists 1.54 % 1.69 %

Speech pathologists and audiologist .46 % .50 %

Registered nurses 17.76 % 20.20 %

Licensed practical nurses 7.67 % 7.16 %

Home health aides 37.32 % 31.02 %

Original Source: Occupational Employment Statistics Survey, Bureau of Labor Statistics. Reproduced from: Freeman L. Home-sweet-home Health Care: home health

services growth. Monthly Labor Review. 1995:3, p.104.

diversity of the patient population challenges

home-care staff to be aware of special dietary

practices and acceptable social distance,

touching, volume of voice, gestures, and

eye contact, to name just a few cultural

characteristics.102 One agency that reported a

very diverse patient population made attempts

to match patients with a provider who speaks

the same language. This agency also provides

diversity training and matches new employees

with a mentor from another nationality.

The home health care industry as outlined above, has gone through significant transformations

over the last decade but continues to play a valuable role as part of an integrated continuum of care.

Recent changes in the payment structure appear to have put this industry and the persons its serves

at risk. At this point, the future of home health is unclear. Many indicate that the current trend

of downsizing, reducing costs, managing care and reduction in revenue are likely to continue.

D. L O N G - T E R M C A R E

Due to factors such as shorter lengths of stay in the acute care setting, long-term care residents have a higher severity

of illness and are being treated for more complex medical conditions than in the past. These changes have a

significant impact on the workforce in these facilities, especially the allied health care workers who are increasingly

handling more direct patient care.

Given that skilled nursing facilities account for 94 percent of the long-term care facilities in California and that

residential care facilities provide no nursing services, the focus of the survey and primary data research is on the

skilled nursing facility and associated workforce issues.

Demographics - Long-term care is a generic term used to define all “nursing home” license

classifications, including skilled nursing facilities, intermediate care facilities and

intermediate care facilities/developmentally disabled.k These facilities provide a broad range

of clinical, social and personal care services for people who need assistance over a sustained

65



Pain15%

AIDS16%

Cancer17%

Pediatric13%

Other7% Risk

Pregnancy10%

Psychiatric10%

Cardiac12%

Source: Snow C. Home Health Heats Up: Survey Finds Massive Change at

Industry’s Door. Modern Healthcare. 1997, p.28.

E X H I B I T 17:Ten MostFrequentlyOffered SpecialtyHome-CareServices byNumber of Sites,1997

k. As defined by the Office of Statewide Health Planning and Development in the Annual UtilizationReport of long-term care facilities.


66

period of time to maintain or improve their well being.103 In 1995, there were 1,518 licensed

long-term care facilities in California, including freestanding facilities and facilities that are

associated with an acute care hospital.104 (See Exhibit 18) A majority of the long-term care

facilities are skilled nursing facilities, defined by a level of nursing and supportive care

provided by licensed nurses to patients who need 24-hour nursing service on an extended

basis. Exhibit 19 displays the distribution of the licensed beds of these facilities per 1,000

residents across California counties.

In 1995, California had the highest number of nursing homes in the country and highest

number of certified nursing beds. However, the ratio of nursing home beds per 1,000

population (aged 65 and over) was less than the national average. In California, the ratio

was 37.6 beds per 1,000 population while

nationally it was 53.1 beds.105

In the U.S., the majority of nursing facilities

is proprietary. This is also true in California

where in 1995, of the total 1,048 certified

freestanding skilled nursing facilities, 84

percent were proprietary. (See Exhibit 20) There

is also a trend toward consolidation in the

nursing home industry. In 1995, 51 percent

of the certified nursing facilities nationally

were chain facilities.106 In 1994, the largest

twenty chains operated 18 percent of the total

beds in the U.S.107


E X H I B I T 18: California Profile of Long-Term Care Facilities, 1995

FREESTANDING ACUTE CARE ASSOCIATION TOTAL

Skilled Nursing 1,162 265 1,427

Skilled Nursing/Mental Disorders 50 1 51

Intermediate Care/Other 77 1 78

Intermediate Care/Developmentally Disabled 25 0 25

Congregate Living 30 0 30

Total Facilities 1,252 266 1,518

Source: Office of Statewide Health Planning and Development, Annual Utilization Report of Long-Term Care Facilities, Report Period: January 1, 1995 to December 31,

1995, Sacramento, CA. p. 1,399.

Source: Harrington C, et al. Nursing Facilities, Staffing, Residents,

and Facility Deficiencies, 1991-1995. Report prepared for the Health Care

Financing Administration. San Francisco: University of California, 1996.

E X H I B I T 20:Profit Status

of NursingFacilities in

California, 1995

Non-profit15.1%

Unknown0.3%

Government0.6%

Profit84.0%

67



SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data not Available (7)

1.00 to 2.49 (7)

2.50 to 3.24 (13)

3.25 to 4.24 (14)

4.25 to 4.99 (8)

5.00 to 6.50 (9)

Source: Office of Statwide Health Planning and Development (OSHPD): Long-term Care Facility Annual Financial Data, 1997 (www.oshpd.cahwnet.gov);

1998 Population Estimates, MapInfo Corporation

E X H I B I T 19: Skilled Nursing Facility Beds in California per 1,000 Residents by County, 1997–98


68 Financing - Government programs pay for the majority of U.S. nursing home care. In 1995,

Medicaid (referred to as Medi-Cal in California) paid for an estimated 49.7 percent of the

nation’s nursing home expenditures and Medicare paid 11.8 of total nursing home costs.108

In the 1997-98 budget year, according to the U.S. Health and Human Services’ Inspector

General’s Office, the federal government paid $30 billion to nursing homes in the United

States to pay for the care of 1.6 million elderly and disabled patients.109

Medicare only covers the first 100 days of coverage for skilled nursing facility care. For those

patients whose stay exceeds this limit, they must either pay these expenses out-of-pocket or

reduce their personal financial resources to become eligible for Medicaid-covered nursing

home care. The national average cost for nursing home expenses is between $30,000 to

$50,000 per year. Due to the extreme cost, most residents are forced to spend down their

resources to become eligible for Medicaid. This makes the nursing home industry distinctively

different from hospital or physician services that are primarily covered by Medicare and

private insurance, both of which provide much more generous rates of reimbursements.

In order to receive payment from Medicare and Medicaid programs, long-term care

facilities are required to meet federal certification requirements that were established by

the Health Care Financing Administration (HCFA) under the Social Security Act.110

Skilled nursing facilities are regulated under the Medicare statute Title 19. In order for

facilities to maintain their certification, they must pass annual on-site inspections where

surveyors from state agencies observe care, review records and determine compliance with

national and state guidelines.111

These regulations and guidelines have come under national political scrutiny recently.

In July of 1998, President Clinton proposed sweeping reform of the nation’s nursing home

industry and called for frequent and random inspections of all facilities. Much of this

attention has been focused in California.

Industry Growth - Several federal policy changes in the 1980s have contributed to an

increase in the demand for nursing home services. First, in 1983, Congress adopted the

Medicare Prospective Payment System (PPS) for hospitals that resulted in shortened

lengths of stay and increased number of referrals and admissions to nursing facilities.

Five years later, in April 1988, HCFA changed the criteria for eligibility for nursing

home care, creating another incentive to deliver care in nursing facilities. Specifically,

HCFA issued new Medicare guidelines to the fiscal intermediaries clarifying and


expanding the eligibility criteria for nursing homes. These guidelines eliminated

certain requirements for rehabilitation care and allowed special procedures, such as

intravenous feedings, to qualify for Medicare coverage. This change caused a substantial

increase in the number of federal Medicare dollars that were spent on nursing home

expenses. Finally, in 1988, the Catastrophic Health Care Legislation contributed to an

increase in Medicaid program utilization and costs by establishing and maintaining a

minimum level of asset and income protection for spouses when determining Medicaid

nursing home eligibility.112

An increase in the elderly population is expected to increase the need for long-term care

services. By the year 2050, the elderly population is expected to be nearly six times greater.

The typical patient population in the skilled nursing facility is largely made up of the infirm,

aged or developmentally disabled. Those aged 65 and over are the primary occupants of

skilled nursing facilities. While only 4 percent of the elderly population nationally lives in

a nursing home, this number dramatically increases with age. In 1995, only 1 percent of

persons ages 65 to 74 lived in a nursing home, however 15 percent of all persons age 65 and

over reside in this type of facility.113 The risk of becoming a nursing home resident after age

65 is 43 percent and peaks at age 75 to 80.114

In addition to the growth of the aged population, the severity of illness of the patients in

nursing homes is increasing. Shorter lengths of stay in acute care hospitals and an increase

in the number of referrals to nursing homes are increasing the need for nursing home care.

Hospitals are releasing patients to nursing home facilities that have a higher degree of

medical instability, impairment and severity of illness. Also, medical technology that was

formerly used solely by hospitals is now being more regularly utilized in nursing home

facilities. There has been an increase in the use of intravenous feedings and medications,

ventilators, oxygen, special prosthetic equipment and devices.115 These changes have resulted

in a need for nursing care that is more challenging and complex.

Industry Constraints - While nursing home services have seen an increase in both volume

of patients and in the severity of illness in these patients, there are also some important

factors that now may constrain the growth of the nursing home utilization nationally

and in California. The most significant of these issues is the use of community-based

alternatives, such as home health care services. During the last five years, federal

Medicare policies have expanded coverage to include services that can be provided by

69




70 home health agencies. The growth in the use of home health services has allowed patients

to receive rehabilitative and medical treatments at home rather than being treated in a

skilled nursing facility.

Workforce Issues - Medicare and Medicaid regulations implemented in 1990 require a RN

director of nursing, a RN on duty for eight hours a day, seven days a week, and a licensed

nurse (RN, LPN or LVN) on duty around the clock.116 Both regulations also require that

nursing homes base staffing patterns on the care needs of their patient population. Waivers

for these staffing requirements, however, can be obtained for those areas where it may be

difficult to hire registered nurses.

Due to the ownership structure of many nursing facilities, the desire to maximize profits

has often lead to lower wages and fewer benefits. Also, given that the government is the

largest payer of nursing home care, they are reluctant to increase staffing requirements in

order to reduce costs. In many cases, in order to compensate for the increase demand in

nursing home care, nursing homes are hiring less trained staff. In many cases this results in

an increase demand for certified nursing assistant (CNA).

In October 1996, a total of 324 long-term care facilities responded to a surveyl regarding

the wages and benefits of their personnel. These data indicated that employees of long-term

care facilities, while they receive relatively low wages, are required to pay high premiums to

receive health coverage. For example, while the average hourly starting pay for a CNA was

$5.95, the employee is required to pay an average of 40.8 percent of the premium for

coverage for the employee and their family. (See Exhibits 60 and 61 in Section VA)

The responses of the long-term care interviewees greatly varied regarding benefits

provided. The minimum number of hours required for benefits eligibility ranges from 16

hours to 32 hours; however, most of the sample indicated a minimum of 30 hours. There is

variance among the sample regarding the percentage of employees who is eligible to receive

benefits. The responses ranged from “10 to 25 percent” to “More than 75 percent” of employees

are eligible to receive benefits. The amount of benefit premiums paid by the employee also

varies across the sample. For example, one facility indicated employees who work a minimum

of 32 hours a week pay $25 per pay period for health insurance and an additional $10

for dental coverage. These amounts increase when dependents are added to the coverage.


l. This survey of organization members was conducted by the California Association of Homes and Servicesfor the Aging and the California Association of Health Facilities.

For this respondent, this level of benefit represents an improvement from the coverage

offered under the facility’s previous owner, which cost $163 to $200 per pay period. Other

facilities responded that 25 to 50 percent of the insurance cost is paid by the eligible

employees. The amount paid by employees is the more significant indicator of benefit level,

particularly given the fact that for many employees at the lower end of the pay scale, these

premiums represent large percentages of their income.

Long-term care facilities have traditionally struggled with the issue of high turnover. A

1996 reportm described turnover rates for employees in skilled nursing facilities as

continually high. This report documented that the average turnover rate for employees in

skilled nursing facilities was 42 percent annually. From the Project interviews, respondents

reported a similar trend among CNAs. Most facilities in the Project sample reported a high,

problematic annual rate of turnover for CNAs, which has been described as 100 percent or

higher. Still another source identifying a high annual turnover rate is the 1997 OSHPD data

from long-term care facilities, in which overall employee turnover rate for this care delivery

setting was reported as 67.8 percent.

Facilities have tried to offer bonus programs and other incentives to attract and retain

employees. One facility in the Project’s sample had a low turnover rate for CNAs, estimated

at 15 percent. While this facility does have CNAs who leave their positions due to retirement,

moving out of the area, and some due to promotion, many CNAs stay. The facility’s

Director of Staff Development (DSD) attributed this to “treating their employees well.” The

facility focuses on attendance, teamwork and instilling respect for the CNA role. The DSD

also added that new CNAs at this facility see that some of the CNAs have been there for 10

or more years, which is very motivating.

E. C L I N I C A L L A B O R A T O R I E S

Many diagnostic procedures, treatments and therapies provided in the medical office, hospital, long-term care and

home health settings are based upon the results of laboratory testing. Clinical laboratory testing includes point-of-care

testing performed at or near the patient’s bedside and waived, moderate and high complexity testing performed in

hospital-based labs, physician office labs (POLs) and clinical reference labs, as defined by the Clinical Laboratory

Improvement Amendment 1988 (CLIA). Laboratories range in size, based on the volume of testing per year as well as

71



m. This report was issued by the California Association of Homes and Services for the Aging and theCalifornia Association of Health Facilities.


72 the types or menus of testing conducted. While there are many types of laboratories including public health and research

labs, the focus here is on clinical reference laboratories and the allied and auxiliary personnel who work in these settings.

Demographics - The Department of Health Services, Laboratory Field Services branch (DHS-

LFS) is the oversight agency for California’s laboratories and maintains the databases for all

California registered and licensed laboratories. Depending on the level of testing performed

and the personnel performing testing, laboratories are required to be registered or licensed with

the state and nationally. According to LFS staff, there are approximately 15,000 laboratories

and over 22,000 licensed laboratory personnel in California. Approximately 2/3 of

laboratories are POLs, and each of the 532 hospitals in the state have one or more hospital-

based laboratories. The remainder are reference and other types of laboratories (including

research and public health labs). Following the pattern of downsizing, consolidation and cost-

cutting approaches in other settings of the health care industry, there is a movement towards

increased use of high volume reference laboratory testing. These labs often can handle both a

higher volume of testing as well as higher complexity of testing, and thus, using reference labs is

more cost effective for care delivery organizations. For example, the recent agreement between

the Tenet Health Care system and SmithKline Beecham Clinical Laboratories consolidates the

testing of 30 Tenet hospitals in California into two high-volume core hospital labs.117

Laboratory testing and personnel - As defined in both CLIA and the California Business and

Professions Code 1206.5, laboratory testing ranges from waived, the simplest of testing,

including urinalysis, blood glucose and blood cholesterol, to moderate complexity and high

complexity testing. Clinical laboratory personnel perform testing in many specialty and

subspecialty areas of laboratory science including microbiology, chemistry, hematology,

cytotechnology, immunology, genetics and toxicology. In addition to these areas in which

licensed technologists and unlicensed laboratory assistants work, there are also

phlebotomists who do not perform testing, but do draw and provide samples as well as

other pre- and post-analytic testing functions for laboratories. Laboratory personnel

currently recognized in California fall into fourteen categories across various specialties.

These include the clinical laboratory scientist or technologists who hold one or more type

of laboratory license (formerly called the medical technologist) and the laboratory assistant

who is not licensed. California requires the clinical laboratory technologist to be state

licensed while some other states require only certification.


The state currently does not recognize a mid-level medical laboratory technician

occupation, although, the DHS-LFS is developing a definition for a mid-level medical

laboratory technician (MLT) that would be licensed and recognized to perform limited

testing. In other states, these technicians are licensed to perform those tests waived under

CLIA and some moderate level tests. During the Project interviews, there was some

agreement that adding this technician level to laboratory staff would be effective for both

workforce and cost reasons. Interestingly, some of the labs described positions that filled a

demand for assisting with some of the testing conducted. However, personnel in these

positions did not release test results, a function which is only performed by the licensed

laboratory scientist. From the interviews, it was also learned that there is some crosstraining

of personnel in laboratories, a majority in other technical areas of the laboratory, and for

some smaller laboratories in areas outside the laboratory. Respondents noted that it is

particularly difficult to crosstrain for lab departments where tasks are less automated and

require more judgement such as microbiology.

Regulation and other Issues in Labs - Clinical laboratories have undergone significant

regulatory change, in response to the Clinical Laboratory Improvement Amendment (CLIA

1988) and subsequently the California state law that enacted this federal legislation at the

state level in 1996. This state law in the California Business and Professions Code 1206.5

supersedes the federal law. The law provides regulation of all individuals permitted to perform

or supervise the performance of three levels of clinical laboratory tests described above.

The Laboratory Field Services branch of DHS is responsible for inspecting and ensuring

laboratories are in compliance with the state law, as well as ensuring accuracy of laboratory

testing. This program also oversees the licensing of laboratory personnel. The Clinical

Laboratory Technology Advisory Committee, appointed by the Director of Health Services,

is an interdisciplinary committee that evaluates and makes recommendations regarding

issues pertinent to clinical and other laboratories. In addition to the current proposal to

create an MLT position, recommendations regarding regulation of point-of-care testing

and continuing education requirements for licensed laboratory personnel have been set

forth by this committee.

Additional issues facing laboratory personnel and this setting are significant differences in

test results between POLs and non-POLs, demonstrating ongoing testing competency,

proficiency testing, and advancing and automated testing technology. The cost pressure and

73




74 consolidation in laboratories mentioned above has led to changes in the workforce size and

volume of testing. From the laboratory setting interviews, while four of the five laboratories

indicated they had increased the volume of testing recently, only one laboratory had also

increased the number of personnel, and two actually had decreased the number of

laboratory personnel. In the interviews, human resources and clinical directors noted

specific issues for laboratories which are presented in Challenges for Recruiting, Retaining and

Developing a Qualified Workforce.


Challenges for Recruiting, Retaining and Developing a Qualified Workforce

The following are direct quotes reported on the survey for an open-ended question about

challenges for recruiting and retaining laboratory personnel:

“Wage issues and benefit levels.”

“Workforce issues include heavy workload, staff shortage, organizational changes, and

cash flow due to reimbursement.”

“Salary generally less than in hospital labs and larger reference labs.”

“We have difficulty filling temporary positions. We anticipate difficulty in filling full-time

positions in near future especially with the night shift positions.”

“Recruiting qualified personnel and time required to train and develop. Need individuals

with previous lab experience in a high volume environment. Internet has not been a good

source. Primarily newspaper ads and employee referrals.”

Sections II and III describe seven broad societal trends that impact the allied and auxiliary

health care workforce and the five care delivery settings in which this workforce is

predominantly employed. In order to gauge how these trends relate to and affect

California’s allied and auxiliary health workers, this section presents a picture of the current

workforce’s size, shape and dimensions. Specifically, this section provides a description of

the supply, composition and distribution of California’s allied and auxiliary workforce. It

presents an overview of allied and auxiliary workers’ location of practice among different

care delivery settings, data on the workforce’s gender and racial/ethnic composition, and a

comprehensive description of wage rates. Statistics on the different rates of unionization

among allied and auxiliary workers are also presented as a final descriptive characteristic.

A. S I Z E , C O M P O S I T I O N A N D D I S T R I B U T I O N

Nearly one million people in 1995 were employed in health care facilities throughout the

state of California, representing nearly eight percent of the general workforce.118 Among the

health care providers in this workforce, allied health workers constitute the largest provider

group. Further, the combined allied and auxiliary workforce represents the greatest number

of personnel employed in the entire health care workforce.

The health care industry is one of the largest employers in the state of California and

is expected to grow. Industry projections from the California Employment

Development Department (EDD), Labor Market Information Division estimate that

966,719 people were employed in health care delivery systems in 1995. The EDD data in

Exhibits 21 through 25 estimate the number of people employed in the Standard Industrial

Classification (SIC) 80, which encompasses health care delivery facilities such as

hospitals, clinics, labs and home health agencies. This estimate within SIC 80 does not

include personnel employed in other “health care” industries such as insurance or

health plans, pharmaceutical companies, consulting or biotechnology firms. To note,

EDD estimates in Exhibits 21 through 29 are derived from payroll data, which excludes

75



C H A R AC T E R I S T I C S /D E M O G R A P H I C S of A L L I E Dand AU X I L I A RYH E A LT H C A R E WO R K E R S

S E C T I O N IV


76

self-employed workers. Further, within this data set, allied health is defined as all health

care providers other than physicians, dentists, registered and vocational nurses,

optometrists, podiatrists, psychologists and chiropractors.

At the state level, employment in health care facilities constitutes nearly eight percent of

total employment. Yet, in many rural regions within California, health care employment

represents as much as 14 percent of total employment in the county. Exhibits 21 and 22

illustrate both the number and percentage of people employed in health care in selected

counties throughout California.

Among the nearly one million people employed in California health care facilities in 1995,

personnel are distributed among three broad personnel categories. These three categories that

comprise 996,719 workers are illustrated in Exhibit 23: health care providers (604,912 people or

63 percent); miscellaneous administrative and clerical personnel (310,527 people or 32 percent);

and maids, cleaners, guards and food service personnel (51,280 or 5 percent of the workforce).


E X H I B I T 21: Health Care Employment as a Percentage of Total County Employment, 1995

TOP 5 COUNTIES AND STATE TOTAL HEALTH CARE EMPLOYMENT AS A TOTAL NUMBER OF PEOPLE IN EACHPERCENTAGE OF TOTAL COUNTY EMPLOYED IN HEATLH CARECOUNTY EMPLOYMENT

Napa 14.7% 6,499

Butte 13.4% 8,199

Lake 12.0% 1,441

Shasta 11.1% 5,859

Stanislaus 10.7% 13,269

State Total 7.9% 966,470

Note: Health care employment defined as employment within SIC 80. Based on industry employment projections.

Source: Employment Development Department, Labor Market Information Division, Special Run, 1999. Analysis by the Center for the Health Professions.

E X H I B I T 22: Counties With Highest Numbers of Employment in Health Care, 1995

TOP 5 COUNTIES AND STATE TOTAL TOTAL NUMBER OF PEOPLE IN HEALTH CARE EMPLOYMENT AS ACOUNTY EMPLOYED IN HEALTH CARE PERCENTAGE OF TOTAL COUNTY

EMPLOYMENT

Los Angeles 291,124 7.8%

Orange 82,289 7.1%

San Diego 78,955 8.1%

Santa Clara 54,536 6.6%

Alameda 47,271 7.8%

State Total 966,470 7.9%

Note: Health care employment defined as employment within SIC 80. Based on industry employment projections.

Source: Employment Development Department, Labor Market Information Division, Special Run, 1999. Analysis by the Center for the Health Professions.

Exhibit 24 illustrates the same health care workforce, but in more detailed personnel

categories. In this distribution, allied health care workers constitute 35 percent of the

workforce; clerical and administration represent 32 percent; registered nurses and

licensed vocational nurses represent 22 percent; physicians and dentists represent 5

percent; housekeeping, food service, cooks and guards represent 5 percent; and

chiropractors, optometrists, psychologists and podiatrists constitute 1 percent.

Exhibit 25 examines the composition of

health care providers within the health care

workforce. Of the 604,912 health care

providers, allied health workers represent

56 percent, registered and licensed vocational

nurses represent 35 percent, physicians

and dentists represent 8 percent, and

optometrists, psychologists, podiatrists and

chiropractors represent 1 percent.

It is also interesting to note that for

some occupations associated with the

delivery of health care, such as housekeepers

and cooks, health care represents a

77



RNs & LVNs22%

Maids, Cleaners,Guards and FoodService Personnel

5%

Allied Health35%

Optometrists,Psychologists,Podiatrists &Chiropractors

1%

Physicians & Dentists5%

Miscellaneous Administrative and Clerical Personnel

32%

Note: Workforce defined as personnel employed in organizations within SIC 80.

Payroll data excludes self-employed workers.

Source: EDD, Labor Market Information Division, Special Run, 1999.

Analysis by the Center for the Health Professions, 1999.

Note: Health Care Workforce defined as personnel employed in organizations with-

in SIC 80. Payroll data excludes self-employed workers.

Source: EDD, Labor Market Informationo Division, Special Run, 1999.

Analysis by the Center for the Health Professions, 1999.

E X H I B I T 23: (L E F T)BasicComposition ofCalifornia’sHealth CareWorkforce byPersonnel Type,1995

E X H I B I T 24: (R I G H T)DetailedComposition ofCalifornia’sHealth CareWorkforce byPersonnel Type,1995

Maids, Cleaners,Guards and FoodService Personnel

5%

MiscellaneousAdministrative and Clerical Personnel

32%Health CareProviders

63%

RNs & LVNs35%

Allied Health56%

Optometrists,Psychologists,Podiatrists &Chiropractors

1%

Physicians & Dentists8%

Note: Payroll data excludes self-employed workers. Source: EDD, Labor Market

Information Division, Special Run, 1999. Analysis by the Center for the Health

Professions, 1999.

E X H I B I T 25:Compositionof Health CareProviders inCalifornia, 1995


78

significant percentage of state employment for these occupations. For example, 23

percent of all maids and housekeeping cleaners and 24 percent of all cooks in California

are employed in health care. Exhibits 26 and 27 describe these figures and are based on

special run data from the EDD.n

The distribution of the allied and auxiliary workforce across California

counties is interesting to compare to the total population in each county. These data

are presented in Appendices C and D. With a few exceptions, the majority of the

allied health workforce is concentrated in the Bay Area and in Los Angeles County.

The most recent data available at the California county level is from the EDD

Occupational Employment Projections 1992-1994. To compare the size of this

workforce to the California population, data from the California Department of

Finance, 1994 Historical City/County Population Estimates that are based on 1990

Census counts are used. In presenting this distribution, California’s 58 counties have

been grouped into 10 county consortiums.119 These 10 county consortiums are displayed

and defined in Appendix C.o


Cooks in Non-Health CareSectors

76%

Cooks in Health Care Sector24%

Note: Health care settings defined as SIC 8011-8099. Cooks defined as OES

code 650280.

Source: Employment Development Department, Labor Market Information Division,

Special Run, 1999. Analysis by the Center for the Health Professions, 1999.

Note: Health care settings defined as SIC 80. Maids housekeeping cleaners

defined as OES code 670020

Source: Employment Development Department, Labor Market Information Division,

Special Run, 1999. Analysis by the Center for the Health Professions, 1999.

E X H I B I T 26: (L E F T)

Distribution ofMaids and

HousekeepingCleaners in

Health Careand in

Non-Health CareSectors, 1995

E X H I B I T 27: (R I G H T)

Distribution ofCooks in Health

Care and in Non-Health Care

Sectors, 1995

Maids andHousekeeping

Cleaners inNon-Health Care

Sectors77%

Maids and HousekeepingCleaners in Health Care

Sector23%

n. Health care settings defined as SIC 80. Cooks defined as OES 650280. Maids and housekeepingcleaners defined as OES 670020.

o. This distribution is primarily based on the Office of Statewide Planning and Development’s HealthService Areas map. A few adjustments were made to keep metropolitan service areas in tact.

The distribution of selected allied health care workers across county consortiums are displayed in

the exhibits in Appendix D. The selected professions are: physical therapists, assistants and aides;

clinical laboratory technologists and assistants; radiologic technologists, diagnostic; medical records

technicians; nursing aides/orderlies/attendants; home health care workers; and medical assistants.

According to the 1992-1994 EDD figures, the distribution of allied health care workers parallels the

distribution of the California population. Los Angeles County, where 29.3 percent of the state’s

population resides, tends to have the highest proportion of particular allied health workers as well.

For example 32.3 percent of physical therapy assistants and aides, 34.2 percent of clinical laboratory

assistants, and 36.2 percent of medical records technicians are employed in Los Angeles County.

To note, Los Angeles County has the largest percentage of allied health training programs as well as

the largest percentage of hospital employers among counties in the state.

There are, however, a few distinct exceptions to this pattern. Rural counties tend to have

lower ratios of providers per population than urban counties. For example, the Motherlode

County consortium represents 3.3 percent of the California population, but employs

between 0.3 percent and 0.5 percent of the selected allied health professionals. In general,

urban areas have higher ratios of providers per population. Additionally, some urban areas

employ a disproportionate share of certain occupations. For example, the Los Angeles

County consortium, which is inhabited by 29.3 percent of the state population, has only

14.9 percent of the home health care workers.

B. L O C A T I O N O F P R A C T I C E

The nearly one million health care workers in California are employed in a number of

health care settings, such as hospitals and long-term care facilities. Approximately 43

percent of the health care workforce is concentrated in hospitals, while 21 percent work in

physician offices and clinics, 13 percent work in long-term care facilities, and 9 percent

work within dental offices. The rest of workers are distributed nearly evenly among home

health care agencies (3 percent), medical laboratories (2 percent), offices of health

practitioners (3 percent) and miscellaneous settings (6 percent). Exhibit 28 graphically

depicts these figures for the entire health care workforce.

Among the more than 300,000 allied health care providers in the workforce, personnel are

distributed differently by employment settings. Exhibit 29 demonstrates that 36 percent of

allied health providers are employed in hospitals, 17 percent in physician offices and clinics,

79




80

18 percent in nursing facilities, 14 percent in dental offices, 3 percent in medical laboratories,

2 percent in home health care, 4 percent in offices of health practitioners and 6 percent in

other miscellaneous settings (kidney dialysis centers, specialty outpatient clinics, etc.).

C. G E N D E R A N D R A C E / E T H N I C I T Y

The majority of allied and auxiliary workers are female and the racial composition of

these workers is not representative of the racial distribution in California, according to

the 1990 U.S. Census Bureau data. The workforce exhibits displayed in Appendix E can be

compared to Exhibit E1 (see Appendix E) which shows the gender and race/ethnicity make up of

the state of California.p

According to these data, allied health workers are predominately female. In 1990, while

females accounted for 49.9 percent of the California population, females comprised between

51 and 96 percent of these specific allied health care occupations. For example, in 1990 there

were 7,878 dental hygienists in California with 7,544 or 97.2 percent of these female.


Note: Health care workforce defined as all workers in

SIC code 80. Source: Employment Development Department, Labor Market

Information Division, Special Run, 1999. Analysis by the Center for

the Health Professions.


Distribution ofCalifornia’s

Health CareWorkforce bySetting, 1995


Distribution ofCalifornia’s

AlliedHeath Care

Workforce bySetting, 1995

Physician Offices& Clinics

21%

Hospitals43%

DentalOffices

9%

Medical Laboratories2% MISC.

6%Home Health Care3%

Offices ofHealth

Practitioners3%

Nursing CareFacilities

13%

Source: Employment Development Department, Labor Market Information

Division, Special Run, 1999. Analysis by the Center for

the Health Professions.

Medical Laboratories3%

Home Health Care2%

Offices ofHealth

Practitioners4%

Physician Offices& Clinics

17%

Hospitals36%

DentalOffices14%

MISC.6%

Nursing CareFacilities

18%

p. These are the only data available that provide information on the racial/ethnic composition of specific alliedhealth care occupations in California. They originate from the 1990 Census Equal Opportunity file that is basedon the civilian labor force data from the 1990 decennial census. The professions presented are: respiratorytherapists, occupational therapists, physical therapists, speech therapists and therapists n.e.c.; clinical laboratorytechnologists and technicians; dental hygienists and dental assistants; health records technologists and technicians;radiologic technicians; health technologists and technicians n.e.c.; nursing aides, orderlies and attendants; andhealth aides (except nursing).

Respiratory therapy had the most representative gender composition with 51 percent female

providers and 49 percent male providers. (Refer to Appendix E)

The exhibits in Appendix E also demonstrate that while there is some representation in

certain occupations, the selected allied health care occupations overall are dominated by

Whites and do not represent the ethnic diversity of the California population. For example,

while white females comprised 28.9 percent of the California population in 1990, they

constituted 80.9 percent of dental hygienists and of speech therapists and 70.3 percent of

occupational therapists. The second largest group represented in these exhibits is white

males. Although California’s White population (both male and female) in 1990 represented

57.1 percent of the population, Whites represented 67.9 percent of respiratory therapists,

76.5 percent of occupational therapists and 81.5 percent of physical therapists. There are a

few exceptions. For example, while white females are overrepresented in the radiologic

technician occupation, the Black (male and female) and Asian/Pacific Islander (male and

female) populations are represented in this occupation.

Since the 1990 Census, California’s racial/ethnic composition has become more diverse.

Therefore, in an effort to present the most recent demographic data available, 1996 EEO-1

data for California across four health care settings are presented.q Though significantly less

specific in terms of occupations, these data, parallel to the Census data, illustrate that in

1996 there continued to be an over-representation of females in the health care workforce.

These data also illustrate that the health care workforce became more representative of the

state’s racial/ethnic composition from 1990 to 1996.

The racial/ethnic composition of each of the four settings was similar to that of the

State, with the following exceptions. (See Exhibits 30 to 34) Across all health care settings,

Hispanics were underrepresented. For example, compared to 30.2 percent of the state

population in 1996, Hispanics represented 14.3 percent in hospitals, 23.6 percent in

81



q. The 1996 Employer Information Reports (EEO-1) data were collected as part of a joint commission ofthe Equal Employment Opportunity Commission (EEOC) and the Office of Federal Contract CompliancePrograms (OFCCP). Exhibits 30 to 36 provide the racial/ethnic and gender composition of theCalifornia population and workforce across four Standard Industry Codes: medical offices (SIC 801),nursing and personal care facilities (SIC 805), hospitals (SIC 806), and allied and other health facilitiesnot elsewhere classified (SIC 809). Seven EEO-1 occupational categories were collapsed into two. Thefirst category, described as “professional”, includes physicians and nurses as well as physical therapists,occupational therapists, respiratory therapists, dieticians and speech therapists, and is assumed to bedominated by nurses. The second category, “non-professionals” includes clinical laboratory technologistsand technicians, dental hygienists and assistants, medical record technologists and technicians, radiologytechnologists and technicians, nursing aides, home health aides, housekeepers and food service personnel.


82


Note: Medical Offices defined as SIC 801. Source: 1996 Employer Information

Report EEO-1. Joint Reporting Committee. Equal Employment Opportunity

Commission and the Office of Federal Contract Compliance Programs (Labor).


Racial/EthnicComposition of

PersonnelEmployed in

CaliforniaMedical Offices,

1996




CaliforniaNursing Facilities,

1996




CaliforniaHospitals, 1996




CaliforniaHealth Facilities,

1996

Black9.8%

White57.7%

Hispanic15.9%

Asian/Pacific Islander16.0%

American Indian/Eskimo/Aleut

6.0%

Note: Nursing Facilities defined as SIC 805. Source: 1996 Employer Information



Black11.9%

White39.7%

Hispanic23.6%

Asian/Pacific Islander

24.2%


0.6%

Note: Hospitals defined as SIC 806. Source: 1996 Employer Information Report

EEO-1. Joint Reporting Committee. Equal Employment Opportunity Commission

and the Office of Federal Contract Compliance Programs (Labor).

Black8.3%

White59.1%

Hispanic14.3%


17.7%


0.6%

Note: Health Facilities defined as SIC 809. Source: 1996 Employer Information



Black11.8%

White56.3%

Hispanic17.1%


14.2%


0.6%

nursing facilities, 17.1 percent in health

facilities and 15.9 percent of medical offices.

In addition, Asian/ Pacific Islander

representation in the nursing facility

setting was 24.2 percent much higher

than that in the state population (10.8

percent). Also in the nursing facility setting,

White representation was lower than that of

the state’s population (39.7 percent

compared to 51.7 percent). Furthermore,

compared to the California state population

which was 49.9 percent female in 1996, females represented 75.9 percent of medical

offices, 75.0 percent of nursing facilities, 73.0 percent health facilities n.e.c and 77.6

percent of hospitals. (See Exhibit 35)

The EEO-1 data also illustrate that occupations in the “professional”category tend

to have even lower racial/ethnic diversity than those occupations in the “non-

professional” category. (See Exhibit 36) In hospitals, for example, Whites constituted

67.1 percent of the “professional” occupations compared to 32.9 percent of the

“non-professionals”. The Asian/Pacific Islander population showed a similar trend

across the four settings, for example constituting 20.8 percent of the “professionals”

in medical offices and 14.0 percent of the “non-professionals”. In contrast, the Black

83



Black6.7%

White51.7%

Hispanic30.2%


10.8%


0.6%

Source: U.S. Bureau fo the Census. Population Projections of the United

States, by Age, Sex, Race, and Hispanic Origin: 1993 to 2050. Current

Population Reports. Prepared by J.C. day Pub. No. P25-1104. Washington DC:

U.S. Department of Commerce, 1993.

E X H I B I T 34:Racial/EthnicCompositionof CaliforniaPopulation,1996

77.6%73.0% 75.0% 75.9%

49.9%

Hospitals Services, nec Nursingfacilities

Medical offices 1996 CAPopulation

Note: nec=Note elsewhere classified.

Source: 1996 Employer Information Report EE0-1. Joint Reporting Committee. Equal Emploment Opportunity Commission and the Office of Federal Contract

Compliance Programs (Labor).

80%

70%

60%

50%

40%

30%

20%

10%

0%

E X H I B I T 35: Female Representation in Four Health Care Settings in California, 1996


84

and Hispanic populations were larger in the “non-professional” category and lower

in the “professional” category across the four health care settings. For example, in

health facilities, n.e.c., Blacks made up 7.8 percent of the “professional” occupations

and 14.6 percent of the “non-professionals”.

D. W A G E R A T E S

Wages for the allied and auxiliary health care workforce vary greatly. This section provides national

and California wage data for this segment of the workforce.r The wage data presented examine:

• the variation of wage rates among:

- specific allied and auxiliary occupations,

- California counties, and

- health care settings;

• the growth and decline of wages during the past decade;

• the relative wage rates for occupations in health care and other industries; and

• the value of educational attainment on wage rates.

Variation in wage rates - Exhibit 37 illustrates the variation in wages from entry-level auxiliary

occupations to the highest skilled allied professions. At the low end of this wage spectrum, nursing


20.8%

7.2%5.8%

14.0%

21.9%

12.3%

29.0%

5.9%6.4%

23.7%

29.4%

14.0%

22.1%

6.1%4.7%

19.5%

7.6%7.8%

15.6%

21.5%

11.5%

23.5%

14.6%

66.2%51.8% 58.7%

32.9%

67.1% 65.1%

51.4% 49.2%

12.6%

MedicalOffices-

Professional

MedicalOffices-

Non-profession

NursingFacilites-

Professional

NursingFacilites-

Non-professional

Hospitals-Professional

Hospitals-Non-

Professional

HealthFacilities-

Professional

HealthFacilities-

Non-professional

HEALTH CARE SETTINGS

PE

RC

EN

T OF TO

TAL E

MP

LOY

ME

NT

100%90%80%70%60%50%40%30%20%10%0%

Note: Medical offices defined as SIC 801; hospitals defined as SIC 805; nursing facilities defined as SIC 806; health facilities defined as SIC 809.

Source: 1996 Employer Information Report EEO-1. Joint Reporting Committee. Equal Employment Opportunity Commission and the Office of Federal Contract

Compliance Programs (Labor).

Asian/Pacific Islander Hispanic Black White

E X H I B I T 36: Racial/Ethnic Composition of Professionals and Non-Professionals in California, 1996

r. The wage data presented are the most recent and specific data available. The data were obtained from varioussources, each with their own method of collection, time frame, sample size, geographic region and categoriesof occupations. Given these inconsistencies, the objective is to describe trends in wages over time and currentwages generally for the allied and auxiliary workforce where data are available. The intent is not to analyzethese data for changes or differences of statistical significance.

and home health aides, dietetic technicians and medical assistants earn $10/hour or less.

Moving to the high end of this spectrum, mean hourly wages increase to $25/hour or more

for occupational and physical therapists and dental hygienists.

Wage rates vary across geographic location as well. Across California counties,

average hourly wages for housekeeping personnel, medical assistants and nursing

aides are displayed in Exhibits F1, F2 and F3 in Appendix F. From the lowest to the highest,

average hourly wages vary by 125 percent, 166 percent and 191 percent respectively for

these occupations. While northern California counties tend to offer wages at the lower

end of the wage spectrum, no particular county or county consortium consistently

offers the highest wages for these occupations. The diverse economic demographics of

the state are also illustrated by the variation in wages for five categories of personnel in

California hospitals. (See Exhibits F4 to F8 in Appendix F) For example, mean hourly wages for

clerical personnel in medical records services range from $6.47 in Mariposa County to

$14.37 in Alameda County.s

Additionally, across two health care settings - hospitals and long-term care facilities

- wage rates differ. Although this comparison has considerable limitations because the

data are collected from two different sources and varying levels of occupational

85



E X H I B I T 37: California Mean Wages for Selected Health Care Occupations andProfessions, 1996

s. Average hourly wages for housekeeping personnel and median hourly wages for medical assistants andnursing aides, orderlies and attendants for 1996 are obtained from the Employment DevelopmentDepartment (EDD). Mean hourly wages for Nurse Aides and Orderlies, Environmental and FoodServices personnel, Technicians/Specialists and Medical Records - Technicians and Clerical personnelemployed in California hospitals are collected from the Office of Statewide Health Planning andDevelopment (OSHPD) for the 1995-96 time period.

Nursing Aides, Orderlies, AttendantsHome Health AidesDietetic TechniciansMedical AssistantsMedical Records TechniciansEmergency Medical TechniciansOccupational Therapy Assisants and AidesPharmacy AidesPharmacy TechniciansDental AssistantsMedical SecretariesMedical and Clinical Lab. TechniciansLicensed Practical/Vocational NursesElectroneurodiagnostic TechniciansRecreation TherapistsElectrocardiograph TechniciansDieticians & NuturitionistsRespiratory TherapistsRadiologic TechnologistsCardiology TechnologistsNuclear Medicine TechnologistsMedical and Clinical Lab.TechnologistsOccupational TherapistsPhysical TherapistsDental HygienistsPharmacists

1 23 4 56 7 89

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Source: California Employment Development Department/Labor Market Information Divison,1996 4th Quarter Occupational Employment and Wage Data, Occupational Employment Statistics (OES) survey results, 1996.

$30

$25

$20

$15

$10

$5

HO

UR

LY W

AG

E

OCCUPATIONS


86

specificity, these data suggest that long-term care wages are much lower than those for

hospitals in California.t (See Exhibit 38)

Growth and decline of wages - Among selected allied and auxiliary health care occupations,

wages for some occupations increased at a rate above inflation during the past decade,

however, wages for other occupations fell below the rate of inflation.u At a national level, Exhibit

39 shows average weekly earnings for physical therapists, all therapists (respiratory,

occupational, physical, and speech therapists and therapists n.e.c.), radiologic technicians, all

health technologists/technicians (including health records) and dental assistants had the highest

percent increases between 1989 and 1996. The wages for these occupations kept pace with or

exceeded the rate of inflation, which was 26.5 percent according to the consumer price index

(CPI)v, particularly those for physical therapists which had a 41.8 percent wage increase.

In contrast, the increases in wages for dieticians, health technologists/technicians n.e.c.,

clinical laboratory technologists/technicians, nursing aides, and health aides were well below

the rate of inflation between 1989 and 1996, with increases of only 11.7 percent, 22.8


E X H I B I T 38: California Average Hourly Wages for Auxiliary Occupations, 1996

AVERAGE HOURLY WAGES*

Nursing Aides and Orderlies Environmental and Food Service

Skilled Nursing Facilities** 7.29 6.78

Hospitals 10.87 11.44

* Two Office of Statewide Health Planning and Development (OSHPD) personnel categories are presented for 1996-97 data.

** For Skilled Nursing Facilities, average hourly wages for Certified Nursing Assistants and Restorative Aides were aggregated to represent Nursing Aides and

Orderlies for 1996. Average hourly wages for Diet Technicians, Cooks and Housekeepers were aggregated to represent Environmental and Food Services for 1996.

t. Hospital data were obtained from the Office of Statewide Health Planning and Development (OSHPD) for the1996-97 report period. Skilled Nursing Facility data were collected by The California Association of Homes andServices for the Aging (CAHSA) and California Association of Health Facilities (CAHF) for 1996. The CAHSAand CAHF presented the first joint report on wages and benefits of employees in long-term care facilities.

u. The Bureau of Labor Statistics (BLS) maintains national wage information over time according to standardindustry classification (SIC) and occupational employment statistics (OES) classification codes. Medianusual weekly earnings for all full-time workers is collected from the Current Population Survey, which isadministered to 50,000 households monthly.

v. There are two potential indicators of inflation of consumer prices. The gross domestic product (GDP)deflator is a broad measure of prices of all goods produced in the U.S. economy over time, whereas theconsumer price index (CPI) is an index of the prices of particular consumer goods including imports.With inflation fairly low recently, the two indices do not differ significantly, particularly for the generalcomparisons made here. For this examination of wages, the CPI was used.

percent, 22.9 percent, 19.7 percent and 13.4 percent respectively. (See Exhibit 39) This is

similar to the trend seen in nursing wages, where registered nurses had only a 22.5 percent

increase in median weekly earnings during these years.

Another way to evaluate the change in wages is to adjust wages for inflation and

observe how much actual wages grow. Exhibits 40, 41 and 42 illustrate the adjusted wage

trends for selected therapeutic, technologist/technician and service related occupations.

Additionally, each exhibit presents the trend in adjusted wages for a similar

occupation outside of health care. Adjusting for inflation, physical therapists was the

only occupation that had an overall substantial increase in wages between 1989 and

1996 (See Exhibit 40). Other health care occupations had wage rates that were stable

during these years. Furthermore, many of the occupations had wages remain stable or

even drop in more recent years. For example, between 1993 and 1996, clinical lab

technologists/technicians and radiologic technicians (See Exhibit 41) and health aides and

nursing aides (See Exhibit 42) all had a drop in wages. These trends are similar to those for

registered nurses’ wages during the same time period.

These trends in wages for allied and auxiliary occupations can be compared to those for

similar occupations in other industries. In this comparison, adjusted wages for teachers

showed stability or slight declines similar to all therapists (respiratory, occupational,

physical, and speech therapists and therapists n.e.c.) and registered nurses (see Exhibit 40).

Moreover, personal service occupations (including attendants and child care workers)

87



* Note: Includes occupational classification codes: respiratory (098). occupational (099), physical (103), and speech (104) therapists, and therapists nec (105).** Note: Includes occupational classification codes: clinical laboratory (203), dental hygienists (204), Health record (205), radiologic (206), and Health nec (208) technologists and/or technicians.Source: Current Population Survey, Bureau of Labor Statistics. National samples for 1989 and 1996. Analysis by the Center for the Health Professions.

Median weekly earnings - 1989 Nominal change in earnings - 1996

MEDIAN WEEKLY EARNINGS (DOLLARS)

Registered nurses

Physical therapists

All Therapists (Resp., Occ., Phys, Speech, therapists nec) *

Dietitians

Health technologists/techs nec

Radiologic technicians

Clinical lab technologists/techs.

All Health technologists/techs.(incl Health records) **

Nursing aides

Health aides

Dental assistants

AVA

ILA

BLE

OC

CU

PATI

ON

S

100 200 3000 400 500 600 700 800

22.5%

41.8%

31.5%

11.7%

22.8%

28.5%

22.9%

26.8%

19.7%

13.4%

28.9%

E X H I B I T 39: Percent Change in Median Weekly Earnings (Unadjusted), 1989 to 1996


88


950

900

850

800

750

700

650

600

550

*Note: Includes occupational classification codes: respiratory (098), occupational (099), physical (103), and speech (104) therapists; and therapists nec (105)

Source: Unpublished tabulation from the Current Population Survey, Bureau of Labor Statistics. CPI, national city average used to adjust for inflation. Analysis by

the Center for the Health Professions.

WE

EK

LY E

AR

NIN

GS

(IN 1996 D

OLLA

RS

)

1989 1990 1991 1992 1993 1994 1995 1996

Teachers, postsecondary

Teachers, not postsecondary

All Therapists (incl. Resp, Occ,Phys, Speech, therapists nec)*

Physical therapists

Registered nurses

750

700

650

600

550

500

450

400

*Note: Also includes Broadcast equipment operators, airplane pilots, legal assistants and technicians, nec. **Note: Includes occupational classification codes:

clinical laboratory (203). dental hygienists (204), Health record (205), radiologic (206), and Health nec (208) technologists and/or technicians.



WE

EK

LY E

AR

NIN

GS

(IN 1996 D

OLLA

RS

)

Technicians, not health/science(incl. Computer programmers)*

All Health technologists/techs.(incl. health records)**

Clinical lab technologists/techs.

Radiologic technicians

Health technologists/techs.

1989 1990 1991 1992 1993 1994 19961995

400

375

350

325

300

275

250



Dental assistants

Health aides

Nursing aides

Personal service occupations(incl. Attendants andChild care workers)

1989 1990 1991 1992 1993 1994 1995 1996

WE

EK

LY E

AR

NIN

GS

(IN 1996 D

OLLA

RS

)

E X H I B I T 40: National Median Weekly Earnings (Adjusted for Inflation), for Selected Therapeuticand Teaching Occupations, 1989 to 1996

E X H I B I T 41: National Median Weekly Earnings (Adjusted for Inflation) for Selected Technologist/Technician Occupations, 1989 to 1996

E X H I B I T 42: National Median Weekly Earnings (Adjusted for Inflation) for Selected Service Related Occupations, 1989 to 1996

showed similar stability or slight declines in adjusted wages between 1989 to 1996 as did

dental assistants and nursing aides. (See Exhibit 42) While technicians, outside of health

care/science (including computer programmers) showed a flat rate or slight decline overall

similar to health care technologists and technicians (see Exhibit 41), these non-health care

technicians saw an increase in weekly earnings between 1992 and 1996.

The data available for California wage rates over time demonstrate a slight decline in earnings.w

Although the broad categories of hospital personnel presented in Exhibit 43 do not allow specific

trends in wages to be revealed, these data demonstrate that allied and auxiliary personnel wages

remained stable or declined between 1993 and 1997 when adjusting for inflation. This trend is

similar for registered nurses in California hospitals. Furthermore, without adjustment, wage

rates increased at a rate of 5.3 percent for Technicians/ Specialists, 4.7 percent for Nursing Aides

and 6.0 percent for Environmental and Food Services. These rates were below the rate of

inflation for consumer prices which was 8.6 percent between 1993 and 1997.

Comparison of wage rates for health care and other industries - Nationally, wage rates for selected

occupations are higher in health care than in other industries. (See Exhibit 44) For health and

nursing aides, food preparation and service occupations, cleaning and building service

89



1993-94 1996-97

27.40

10.87

11.72

11.27

11.44

26.16

30.00

25.00

20.00

15.00

10.00

5.00

Source: Office of Statewide Health Planning and Development. Aggregate Hospital Financial Data Summary. CPI, national city average used to adjust for

inflation. Analysis by the Center for the Health Professions.

HO

UR

LY W

AG

ES

(IN 1996-97 D

OLLA

RS

)

Registered nurses

Technicians/Specialists

Nursing Aides

Environmental and

Food Services20.87 20.23

E X H I B I T 43: Hourly Wages (Adjusted for Inflation) for California Hospital Occupational Categories, 1993-94 to 1996-97

w. At the state level, fewer wage data are available over time, in part due to small sample sizes at regionallevels from national sources. For California, the Office of Statewide Health Planning and Development(OSHPD) collects hourly wages for broad categories of personnel that are available over time. Averagehourly wages from the OSHPD report periods 1993-94 and 1996-97 are presented for Technicians/Specialists, Environmental and Food Services and Nursing Aides to represent allied and auxiliary workersin California hospitals. Depending on the personnel category, the hourly wage rates reflect an averageacross the applicable hospital services.


90

occupations, and personal service/attendant occupations, wages are higher for those

employed in health care than in all other private industries (not including health care).

For example, food preparation and service occupations in health care earn $257 on average

compared to $212 in all private industries.

Across specific industries - health care, personal services and retail trade - health care

wages are also higher for selected occupations on a national level. (See Exhibit 45) For example,

median usual weekly earnings are higher in the health care industry for financial records and

cleaning and building services occupations than in the personal services and retail trade

industries. One notable exception is food preparation and services occupations in health

care. These occupations earn more on average in health care than those in retail trade ($257

compared to $205); however, they earn much less than those employed in the personal

services industry ($257 compared to $316).

Wage rates according to educational attainment - Examining wages for occupations within and

across levels of educational attainment shows a high rate of return on educational

investment for entry-level occupations in health care. Exhibit 46 displays national average

wage rates for specific occupations within health care, education, sales/finance and

computer/technology industries for four levels of educational attainment as they apply.

Not surprisingly, across these industries, higher levels of educational attainment

correlate to higher wage rates. Some other noteworthy patterns are observed.

First, occupations in health care at the high school, some college or associate’s degree, and

bachelor’s degree educational attainment levels earn higher average weekly earnings than

teachers (not postsecondary) and teacher’s aides in education, and sales and retail personnel


$286$257

$212

$288

$257 $262

$236

$266

Health Care Industry

All Private Industries

(excluding Health Care)

Health and NursingAids

Food Preparationand ServiceOccupations

Cleaning & BuildingService Occupations

Personal Service/Attendant Occupations

WE

IGH

TED

ME

DIA

N U

SU

AL W

EE

KLY

EA

RIN

GS

300

250

200

150

100

50

0

Source: Bureau of Labor Statistics. Current Population Survery. Estimates for Usual Weekly Earnings. National level data.

E X H I B I T 44: Wage Rates for Selected Occupations in Health Care vs. All Private Industries, 1998

in sales/finance. In contrast, health technologists/technicians earn lower average weekly

earnings at all educational attainment levels than technologists/technicians in the

computer/technology industry.

Additionally, at the highest educational attainment level for health care occupations,

there is a lower return on educational investment compared to occupations in other

industries. For example, at the graduate or professional degree level, teachers

(postsecondary) earn $829 average weekly earnings, sales and finance personnel earn

$957, and computer occupations earn $1,046. These earnings offer more financial

opportunity than nursing occupations (whose average weekly earnings are $768),

therapists ($734) and health technologists/technicians ($622) at the graduate or

professional degree level in health care.

91



Health Care

Personal Services

Retail Trade

$405

$345

$257

$316

$205

$288

$220$231

$345

WE

IGH

TED

ME

DIA

N U

SU

AL W

EE

KLY

EA

RIN

GS

450400350300250200150100500

Financial Records Food Preparation and Services Cleaning & Building Services

Source: Bureau of Labor Statistics. Current Population Survey. Estimates for Usual Weekly Earnings. National level data.

OCCUPATIONS

1200

1000

800

600

400

200

0

Source: Bureau of Labor Statistics. Current Population Survey. Estimates for Usual Weekly Earnings. National level data.

OCCUPATIONS

WE

IGH

TED

ME

DIA

N U

SU

AL W

EE

KLY

EA

RIN

GS

$957

$796

$399

$515

$833

$738

$531

$614

$1,046

$905

$580

$706

$331

$404

$195$224

$829

$290

$160

$768

$674

$270

$457

$796

$598

$283$251

$304

$247$256

$734$706

$301

$581$622

$588

$407

$440

Nur

sing

The

rapis

ts

Hea

lth T

echs

Teac

hers

(post

seco

ndar

y)

Teac

hers

(not post

seco

ndar

y)

Teac

hers

Aid

es

Sal

es a

nd F

inan

ce

Sal

es a

nd R

etai

l

Tech

s N

ot H

ealth

Com

put

er

Occ

upat

ions

High school or less Some college or Associates Bachelors Graduate or professional

E X H I B I T 45: Wage Rates for Selected Occupations in Health Care, Personal Services and Retail Trade Industries, 1998

E X H I B I T 46: Wage Rates for Selected Occupations in Health Care, Education, Sales/Finance and Computer/Technology Industries by Educational Attainment, 1998


92

California average wages for related allied and auxiliary occupations also demonstrate a

return for educational attainment. 1996 median wages for three groups of occupations for

California are presented in Exhibits 47, 48 and 49. These exhibits show that higher wages are

earned by the higher skill level occupations within these three groups. The lower wages

reflect the lower level of educational attainment required for the less skilled occupations.

For example, pharmacy technicians and pharmacy aides that require a high school diploma

earn only 34 percent of what licensed pharmacists earn who are required to have a bachelor’s

plus at least one year of additional preparation. In addition, occupational therapy assistants

and aides earn 41 percent of what registered occupational therapists earn who are required

to have a bachelor’s degree, and clinical laboratory technicians and assistants earn 56

percent of what licensed technologists earn on average.

E. U N I O N A F F I L I A T I O N

Nearly 17 percent of California’s health care workforce is represented by organized labor, a

greater proportion than the national average of approximately 11 percent.120

Given the significant presence of unionized health care labor in California and recent

efforts to boost this membership among service sector workers, statistics on the type and

variety of health care representation are described in this section. Where sample sizes from

the Bureau of Labor Statistics (BLS) permit such comparison, data for the state of

California are included as well, illustrating the variation of unionization rates among health

care settings, professions and occupations.


Pharmacists

ES

TIM

ATE

D N

UM

BE

R

ME

DIA

N H

OU

RLY

WA

GE

PharmacyTechnicians

PharmacyAides

$35.00

$30.00

$25.00

$20.00

$15.00

$10.00

$5.00

$0.00

Source: California Employment Development Department/Labor Market

Information Division, 1996 4th Quarter Occupational Employment and Wage

Data, Occupational Employment Statistics (OES) survery results, 1996.

$11.11

30,000

25,000

20,000

15,000

10,000

5,000

0

$32.49

$11.06

OccupationalTherapists

ES

TIM

ATE

D N

UM

BE

R

ME

DIA

N H

OU

RLY

WA

GE

OccupationalTherapy

Assistants and Aides

$30.00

$25.00

$20.00

$15.00

$10.00

$5.00

$0.00




3,000

2,500

2,000

1,500

1,000

500

0

$24.83

$10.09

E X H I B I T 47: Pharmacists, Pharmacy Technicians and Pharmacy Aides, California Median Wage andEstimated Number Employed, 1996

E X H I B I T 48: Occupational Therapists and Occupational Therapy Assistants and Aides, California Median Hourly Wage and Estimated Number Employed, 1996

Unions serve as a voice for workers and strive to improve wages, benefits and working

conditions, protect union jobs, address worker grievances, negotiate contracts and represent their

members in political arenas. Some unions also provide benefits packages for members and their

families, sponsor training programs, and provide educational seminars to promote professional

development. Many unions are also developing new and increasingly collaborative relationships

with their industry partners, a development that is discussed in greater depth in Section V.

Union Representation among Different Health Care Settings, Occupations and Industries In 1998,

unionized workers represented 11.1 percent of the nation’s health care industry. Yet, during

the same year, 16.9 percent of California’s health care workforce was represented by

organized labor. In addition to variation among rates of unionization at the national and

state levels, different health care employment settings have varying levels of representation.

Hospitals, which employ the largest number of health care workers, have the highest union

representation. In 1998, union representation accounted for 14.9 percent of the hospital

labor force, compared to 10.8 percent in nursing and personal facilities, 9.1 percent in

other health services and 3.3 percent in medical offices.x (See Exhibit 50)

Union representation also varies by health care occupation and profession. While

therapistsy and registered nurses had the highest union representation nationally, 19.6 and

93



Medical and Clinical Lab.Technologists

ES

TIM

ATE

D N

UM

BE

R

ME

DIA

N H

OU

RLY

WA

GE

Medical and Clinical Lab.Technicians

$25.00

$20.00

$15.00

$10.00

$5.00

$0.00




18,000

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0

$12.76

$22.61

E X H I B I T 49: Medical Laboratory Technologists and Technicians, California MedianHourly Wage and Estimated Number Employed, 1996

x. Medical Offices include industry classifications 812-830: offices and clinics of physicians (812); dentists(820); chiropractors (821); optometrists (822); and health practitioners not elsewhere classified (830).

y. Therapists include occupational classification codes 098-105: respiratory therapists (098); occupationaltherapists (099); physical therapists (103); speech therapists (104); and therapists n.e.c (105).

16.0%

14.0%

12.0%

10.0%

8.0%

6.0%

4.0%

2.0%

0.0%

Note: *Medical Offices includes offices from current population survey industry

classifications 812-830: offices and clinics of physicians (812), dentists (820),

chiropractors (821), optometrists (822) and health practitioners not elsewhere

classified (830). Source: Current Population Survey, Bureau of Labor Statistics,

1998 annual averages. Estimates for union representation.

HEALTH CARE SETTING

Hospitals Nursing and

PersonalFacilities

HealthServices

n.e.c.

MedicalOffices*

14.9%

10.8%

9.1%

3.3%

E X H I B I T 50: National Union Representation by Health Care Setting, 1998


94

16.8 percent respectively, health-diagnosing occupationsz had the lowest union

representation at 7.9 percent. With the exception of therapists, unions represented 10 to 12

percent of allied and auxiliary health care occupations. (See Exhibit 51)

Compared to other industries with unionized workforces, the health care industry’s rate

of unionization, 11.1 percent, was the second highest in nation in 1998. (See Exhibit 52)

Health care fell only behind the manufacturing industry in terms of unionization rates

(16.8 percent), and was greater than the personal services industryaa (7.6 percent), the retail

trade industry (5.7 percent) and the agriculture industrybb (1.8 percent). (See Exhibit 52)

Although many unions are now focusing membership drives on health care service

workers, union representation in the health care industry has actually decreased since 1983,

a period when all industries experienced drops in membership. Interestingly, union

representation in the health care industry experienced a decrease in membership to a lesser

extent than other industries during this period. For example, while the manufacturing

industry had a 13.8 percent decrease in union representation among workers from 1983 to

1998, union representation in the health care industry decreased 7.1 percent.

The variety of unions representing health care workers - Health care workers are represented by a

variety of unions nationwide, including the United Food and Commercial Workers


16.8%

7.9%

10.8%

19.6%

11.2% 12.3%

Health DiagnosingOccupations*

Registered Nurses Licensed PracticalNurses

Therapists** Health Technologistsand Technicians***

Health ServiceOccupations****

PE

RC

EN

T OF W

OR

KE

RS

Note: *Includes occupational classification codes 084-089: physicians (261), dentists (085), veterinarians (086), optometrists (087), podiatrists (088)

**Includes occupational classification codes 098-105: respiratory therapists (098), occupational therapists (099), physical therapists (103), speech therapists (104),

therapists nec (105)

***Includes occupational classification codes 203-208: clinical laboratory technologists and technicians (203), Dental hygienists (204), Health record technologists and

technicians (205); radiologic technicians (206); health technologist and technicians, nec (208)

****Includes Occupational Classification Codes 445-447: Dental assistants (445); health aides, except nursing (446); nursing aides, orderlies, and attendants (447)

Source: Current Population Survey, Bureau of Labor Statistics, 1998 annual averages. Estimates for union representation. National level data.

HEALTH CARE OCCUPATIONS

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

E X H I B I T 51: National Union Representation of Selected Health Care Occupations, 1998

z. Health diagnosing occupations include occupational classification codes 084-089: physicians (261);dentists (085); veterinarians (086); optometrists (087); and podiatrists (088).

aa. Personal services industry excludes personal services, private households.bb. Estimate based on a small sample size.

International Union (UFCW), the Service Employees International Union (SEIU), the

California Nurses Association (CNA), and the International Federation of Professional and

Technical Engineers (IFPTE). SEIU and UFCW are two of the largest unions representing

allied and auxiliary workers across health care settings. These unions vary greatly by size,

health care worker representation and geographic presence.

As of July 1998, the United Food and Commercial Workers International Union

(UFCW) held an international membership of 1,254,643. Of these national members,

approximately 8 percent (100,000) were employed in health care settings. UFCW

members work in a variety of health care settings, including hospitals, nursing homes,

medical and dental laboratories and home health agencies. Their members include

registered nurses, certified nursing assistants, licensed practical nurses, pharmacists,

technicians, and dietary and food service workers.

In California, SEIU represents approximately 55,000 health care workers, including

certified, licensed and registered nurses, dietary and environmental services workers,

paramedics, doctors, respiratory therapists, lab technicians, pharmacists, home care providers

and clerical workers. SEIU Local 250, representing health care workers in Northern

California, has 40,000 members divided between its six divisions: Kaiser Permanente,

hospitals, convalescent care, home care, physicians and emergency medical services. With a

membership between 15,000 to 16,000 health care workers, SEIU Local 399, represents

health care workers in private institutions in Southern California.

95



Manufacturing

Health Care

Personal Services*

Retail Trade

Agriculture**

35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

Note: *Excludes personal services, private households. **Estimation based on small sample size.

Source: Current Population Survey, Bureau of Labor Statistics, 1998 annual averages. Estimates for union representation. National level data.

PE

RC

EN

T RE

PR

ES

EN

TED

IN IN

DU

STR

Y

1983 1988 1993 1998

E X H I B I T 52: Percent Union Representation by Industry, 1983 to 1998


96

The cost pressures of managed care described in Section II of this report have forced providers

to reorganize themselves in fundamental ways. Hospitals are run with unprecedented attention

to bottom-line efficiency. Providers are forced to spend less time with patients, respect practice

guidelines and protocols and negotiate reimbursement with health plans.

Perhaps no players in the health care system have been challenged more than allied and

auxiliary health care workers. Because of their numbers, their versatility, and their pervasive

influence over the quality and efficiency of the health care experience for every patient, their

roles have been adjusted endlessly in recent years as provider organizations seek the best mix

of skills and paygrades. As a result, allied and auxiliary workers must be prepared to be

deployed in a variety of new ways as health systems seek the strategy that will best balance good

medicine and fiscally responsible business.

Supported by literature review and interviews, the following section outlines the core trends

affecting the scope, compensation, and influence of the allied and auxiliary health workforce.

This employer perspective on the changes in care delivery is supplemented with the worker’s

view, with a description of how workers see the changing environment in which they work.

The picture that emerges is one of uncertainty and constant change, but no dramatic

erosion of compensation. The tensions in the workforce largely center on pay levels at the

lowest skill levels, in which tremendous responsibility is being asked of these employees for

relatively low wages. Not only has responsibility for these workers earning little over

minimum wage grown, but multiskilling efforts required of this workforce, described in

detail below, typically offer no increases in pay. Conversely, at the higher levels, tension will

continue around support of wage rates that may be high in relation to similar jobs in other

industries requiring the same level of skill preparation.

At the same time, issues of performance and productivity have and will continue to exert

tension across all levels of the health care workforce. While most other industries in the late

1980s and 90s moved to compensation structures that link pay with performance, a sizeable

portion of the health care workforce has become used to a generous wage system that paid

wages based on seniority rather than productivity. This is particularly seen in unionized


C H A L L E NG E S for T H EA L L I E D and AU X I L I A RYH E A LT H C A R E WO R K FO R C E

S E C T I O N V

health care facilities. However, as health care strives to meet cost pressures, the pressure to

link pay with performance will only intensify.

Also prevalent within the health care system are high rates of turnover, particularly for the least

skilled segment of the workforce. While there are various reasons for turnover, only a small percentage

of allied and auxiliary workers leave a job to advance to other health care occupations. Regardless of

whether it is the employers’ responsibility to designate and support career tracks or whether the

employee must take all the initiative for career advancement through enhancing skills, there seems

to be little mobility among allied and auxiliary workers, particularly at the lowest skill levels.

While the lack of articulated educational programs for many of the allied health professions

has historically been problematic, opportunities for advancement within entry-level

positions may have worsened. A considerable chasm in viewpoint exists between employers

who view the employee as solely responsible for skill and competency upgrades and the

traditional view of a career trajectory with clearly defined opportunities for advancement.

Finally, while there have been national efforts to create new relationships between unions

and care delivery, there are still tremendous gaps in understanding from both groups. From

a change process perspective, it may prove productive to involve unions more collaboratively

from the beginning of the change process rather than at the end. However, the more

fundamental issues of wage rates and linking compensation to performance still need to be

addressed regardless of others changes taking place.

A. T R E N D S I N T H E A L L I E D A N D A U X I L I A R Y W O R K E N V I R O N M E N T

As California’s health care institutions respond to the pressures of change, patterned responses

are emerging. Behind all these efforts is an emphasis on improving productivity, without

compromising quality or safety. This section describes the following responses by care delivery

organizations that affect the allied and auxiliary workforce.

1. Transfer of Work

2. Multiskilling

3. Changing Demands in Education and Training

4. Outsourcing, Subcontracting and Temporary Workers

5. Changing Career Expectations

6. Pressure on Benefits and Wages

7. The Changing Role of Unions

97




98 The information presented here was drawn from a literature search of biomedical, business

and management professional journals, secondary data from state and national sources including

the Employment Development Department and the Bureau of Labor Statistics, along with

interviews and focus groups. Human resource directors and administrators from four care

delivery settings — hospitals, skilled nursing facilities, home health agencies and clinical

laboratories — were queried, as were members of educational institutions, professional

associations and regulatory entities. A more detailed discussion of methods and sample size can

be found in Appendix A.

1. TRANSFER OF WORK

Labor represents the health care system’s most costly input, and care delivery organizations

have in recent years sought to reduce overhead by transferring work to the least costly

provider who can deliver care at an acceptable level of quality.

Within the allied and auxiliary health care fields, a hierarchy of skilled providers is

emerging. At the highest skill level, technologists and therapists (frequently trained at the

baccalaureate, masters, and occasionally the doctorate level) now supervise teams of

technicians, assistants and aides. Their expertise will be called upon to design care plans and

consult with others in complex cases and diagnoses.

A new set of technician and assistant level positions, often requiring training at the

associate degree level, has emerged to carry out the bulk of “hands-on” routine procedural

clinical work. Additionally, a third tier of workers at the aide or assistant level now exists

throughout most health care settings. These workers frequently receive little to no formal

education but are trained on the job to assist technicians, technologists and therapists.

While this category of workers constitutes the bulk of providers in hospitals and long-term

facilities, it is the newest and least explored segment of the workforce.

Before today’s cost conscious era, providers did not always practice to the fullest extent of

their training and expertise. Baccalaureate trained nurses, for example, used to routinely

administer intravenous feeding and turn immobilized patients. Today, most such tasks have

been relinquished to LVNs and nurse aides.

Care delivery systems are still experimenting to determine optimal staffing patterns. Some

have reduced staffing ratios of licensed providers in favor of transferring care to aides and

assistants, only to return to previous staffing levels. Some of the skill mix ratios highlighted


from the hospital and long-term care surveys support these varying staffing patterns, though

not necessarily favoring a higher ratio of least costly providers. Across the hospital sample,

the skill mix for physical therapy ranged from 9 to 13, with fewer PTs than PT Assistants and

Aides combined, to 5 to 2, indicating more than twice as many PTs as PT Assistants and

Aides. However, most of the sample reported close to a one to one ratio for these personnel.

There was more variability reported in ratios for medical technologists to lab assistants, but

due to license requirements, this category of workers is less open to staffing flexibility.

In the long-term care delivery setting, respondents from the survey reported an average

ratio of two CNAs to one licensed nurse (including RNs, LVNs and LPNs). Three out of 15

respondents indicated a ratio closer to three to one. For the clinical lab sample, the skill mix

was highly varied. The ratios of clinical laboratory scientists to lab assistants were 3 to 4, 1 to

1, 3 to 2, 3 to 1, and almost 4 to 1. Given how the question was asked, it is not clear if the

skill mix in laboratories includes a mid-level position between the licensed laboratory

scientist and the unlicensed lab assistant. It is also important to note that a position distinct

from lab assistant, called a specimen processor, was identified by many of the laboratories.

One example of a care delivery organization experimenting with optimal staffing patterns

is a 350-bed hospital in Southern California that implemented a new workforce redesign

across several departments. In this case, environmental service workers took on simple

patient contact duties, including the delivery of food. Through the hospital’s frequent

patient satisfaction measures, it was discovered that in obstetrics/gynecology and some

medical/surgical units, patients preferred interfacing with fewer providers throughout their

stay. But within the Intensive Care Unit, surgery, and the burn unit, patients were not happy

having the same person who took care of housekeeping duties also delivering their food

trays. As a result, the hospital changed its care plan for specific departments.

While this experimentation and transformation is difficult and challenging, it is also one

that cannot be avoided. The greatest challenge will be to determine through discernable

outcomes measurements, what staffing combinations will be most appropriate. Those will

vary by facility and among departments.

2. MULTISKILLING

Multiskilling involves crosstraining health care workers in skills from more than one discipline.

The germane functions can include support, clinical and management activities and may be at

99




100 higher, lower or parallel skill levels than affected health care workers are used to operating.121

The goals of multiskilling are to reduce the number of providers coming in contact with patients,

improve continuity of care, reduce costs, and improve the overall quality of care and patient

satisfaction. A multiskilled workforce is also a flexible workforce. Workers with skills in a number

of functional areas can be moved from one area of the hospital to another based on patient

census or to cover for absent employees. When implemented properly, multiskilling may reduce

costs while increasing quality of care and the satisfaction of consumers and workers. However,

the challenges that employers, educators and workers face in implementation are numerous.

Multiskilling is actually not new. Before hospitals evolved into the highly specialized institutions

that they are today, physicians and nurses practiced as primary care givers. Small and rural hospitals

have long used multiskilled providers to make up for their shallow talent pool. X-ray technicians

(also called radiographers) on the night shift might have been crosstrained to do EKGs and some

basic lab testing, for example, to keep from employing three different specialists who could not be

kept busy in their respective areas. Sherry Makelycc explains that “[this] process met the needs of

small/rural hospitals for many years.” Additionally, “since it involved relatively small numbers of

providers, crosstraining at that time was not particularly controversial or problematic.”122

Workforce Redesign - Multiskilling is frequently a component of workforce redesign. It is also

the hallmark of ‘patient-focused care’ (PFC), and a number of variations on that theme.dd PFC

emerged as a concept to address patient satisfaction issues that could also result in labor cost

reduction. It is a complex undertaking and some of its components include: simplifying work

processes, placing patient services closer to the patient, broadening employees’ knowledge and

skills, streamlining documentation and grouping patients based on resource requirements.123

As a result, PFC’s implementation has been inconsistent, its various manifestations termed a

“combination of innovation and desperation.”124

The Three Types of Multiskilling - Makely’s 1998 how-to manual on multiskilling for

employers and educators was based on ten years of experience and interviews with

hundreds of employers across the country. In this book, Makely groups multiskilled

providers into three general categories: clinical generalists, support generalists, and

administrative/clerical generalists.


cc. Based on Sherry Makely’s ‘how-to’ handbook on crosstraining, Multiskilled Health Care Workers.dd. Originally pioneered in the late 1980s, patient focused care was developed at Lakeland Regional Medical

Center in Lakeland, Florida, with assistance from consultants at Booz-Allen & Hamilton.

As multiskilling evolves, so will these categories. Multiskilling, by definition, blurs the

lines between providers and professional scopes of practice. A prime example seen in the

Project’s survey work in California involves new functions and skills for nurse aides.

Although these entry-level workers have minimal health care training, their care duties have

expanded into the clinical realm. Nurse aides (called “care partners” or some other variant)

are being crosstrained to perform phlebotomy and EKGs. This new type of work, which has

been a mixed success, falls somewhere in between category one and two.

• Clinical Generalists provide direct patient care in specific hospital units such as the

medical/surgical unit. The most common examples are: RNs, LVNs (or LPNs),

respiratory therapists, radiographers, occupational and physical therapists, phlebotomists,

EKG technicians, medical technologists and pharmacists. Through crosstraining, these

personnel may take on new names such as “clinical associate,” “clinical partner” or

“technical partner.” Depending on the facility, regulatory requirement, and the extent

to which patient care has been decentralized, these providers may be grouped in teams of

two to four providers and may see patients from admission to discharge. Team

members may provide nursing care, phlebotomy, EKGs, IV therapy and basic, routine

radiography, lab testing and respiratory, occupational and physical therapies.

• Support Generalists are providers who blend traditional housekeeping, maintenance,

food service and patient transport with patient contact. Frequently called “service

associates,” “service partners,” or “patient service assistants,” these workers are

crosstrained to provide housekeeping, basic maintenance, specimen transport and

dietary tray passing. At one end of the training spectrum, housekeeping personnel are

trained in food services and vice versa. At the other end, depending on the extent to

which PFC has been implemented, support and environmental services workers may

also assist nurse aides in turning and transporting patients, answering patient call

buttons and possibly aiding in the collection of routine patient data such as vital signs.

• Administrative/Clerical Generalists originally were unit secretaries, receptionists, business

office staff, insurance or medical records personnel. New multiskilled job titles such as

“unit representatives,” “care center secretaries,” or “administrative associates” describe

personnel who perform multiple functions, such as inpatient admissions, registration

and discharge, insurance verification and processing, reception, chart assembly and

filing, medical records and billing, utilization review, and scheduling.

101




102 Exhibit 53 lists a number of multiskilled work functions that were derived from numerous

employers’ needs assessments.125 While some of the following combinations have been widely

implemented, particularly in hospitals, others represent employers’ wishes for the future. State

licensure regulations have precluded the combining of PT/OT, a combination that has historically

been of interest to employers. However, combinations such as nurse aides/housekeepers,

radiography/ultrasound and RN/respiratory care have been employed for quite a while. Some of

the newer combinations are respiratory therapy/EKG, RN/phlebotomy, OT/PT/Speech

Pathology/Audiology at the technician level, radiography/MLT and Respiratory Therapy/EKG.

Findings from California Hospitals - From a sample of hospitals in California, the Project

confirmed that facilities are pursuing multiskilling with varying degrees of enthusiasm and

success. Some were adamant about not engaging in multiskilling while others seemed to embrace

it as a necessity to stay afloat in a rapidly changing health care environment. Yet few were rigorously

examining the effects of such changes with traditional outcomes measurements.

Some facilities reported creating crosstrained positions among their nursing aides as well as

support staff although differences were found among the hospitals based on size. Among the

small hospitals in the sample, none reported crosstraining for either nursing aides or support

services personnel in new skills related to patient care. In some larger hospitals (100+ beds),

some crosstraining was reported for nursing aides in EKG, phlebotomy, monitoring technician

skills and ward clerk skills. Yet the vast majority of hospitals are not crosstraining their support

services personnel (housekeeping and dietary workers) for inpatient contact. Some noted that

they had tried this in the past, and that it was not successful.

Not surprisingly, smaller hospitals in the sample reported a need for diagnostic imaging

personnel who specialize in multiple modalities, and they reported on-the-job training to

support this need. In contrast, larger hospitals reported both the need for imaging

personnel who could perform multiple modalities, and then specialize in one area. Larger

hospitals are able to hire more staff, and thus can afford to have some personnel specialize

in only one imaging modality. Similarly, these hospitals also reported support for training

in educational programs rather than on the job.

3. CHANGING DEMANDS IN EDUCATION AND TRAINING

Health care employers in California complain that they are not finding the skill sets they

need in the present applicant pool of new graduates and experienced workers. Most of the


103



E X H I B I T 53: Multiskilling Combinations

DIAGNOSTIC IMAGING COMBINATIONS

Radiography/Ultrasound Radiography/Mammography

Radiography/Nuclear Medicine Radiography/Radiation Therapy

Ultrasound (US)/Nuclear Medicine (NM) Radiography/NM/US

Radiography/Electrocardiography (EKG) Radiography/Phlebotomy

Radiography/Med.Lab Technician (MLT) Radiography/EKG/MLT

EKG COMBINATIONS

EKG/MLT EKG/Radiography Therapy

EKG/EEG EKG/Phlebotomy

RESPIRATORY THERAPY COMBINATIONS

Respiratory Therapy/EKG/Phlebotomy Respiratory Therapy/Cardiopulmonary

REHABILITATION SERVICES COMBINATIONS

Physical Therapy/Occupational Therapy Speech Pathology/Audiology

PT/OT/Speech Therapy/Audiology at the technician level

NURSING SERVICES COMBINATIONS

Registered Nurse (RN)/Ultrasound (US) RN/EKG

RN/PT RN/OT

RN/Social Service RN/Paramedic

RN/Respiratory Therapy RN/Radiography

RN/Physician Assistant (PA) RN/Cardiac Catheterization Tech

RN or LVN/Surgical Technologist LVN/EMT

Nursing Aide or Assistant/Housekeeper

MEDICAL ASSISTING COMBINATIONS

Medical Assistant (MA)/EKG MA/Surgical Technologist

MA/Phlebotomy MA/Insurance Coder

MA/Radiographer

NON-CLINICAL SKILL COMBINATIONS

Medical Records/Risk Management Surgical Aide/Housekeeper

Purchasing/Central Supply Admitting/Patient Registration

Central Supply/Laundry Patient Billing/Financial Counseling

Central Supply/Housekeeper Housekeeper/Maintenance

Pastoral Care/Social Services Housekeeper/Transportation Aide

Admitting Clerk/Phlebotomist

DEPARTMENT MANAGER FOR MULTIPLE AREAS

Diagnostic Imaging (Radiology/NA, US, Radiation Therapy) Pharmacy, PT, Respiratory Care

Diagnostics (Radiology, Cardiovascular, Clinical Lab) Rehabilitation Services (PT, OT, Speech Pathology, Audiology)

Patient Business Services (Admitting, Patient Billing, Insurance Rehabilitation)

Housekeeping, Transportation, Maintenance Customer Services, Risk Management

Hotel Services (Food Services, Housekeeping, Customer Service) Protective Services, Risk Management

Medical Records, Coding, Chart Analysis, Utilization Review,Quality Assurance

Reprinted From: Makely, S. Multiskilled Health Care Workers: Issues and Approaches to Crosstraining. IN: Pine Ridge Publications, 1998.

Respiratory Care, EKG, EEG, Sleep Lab

Purchasing, Material Management, Facilities, Central Supply


104 deficits do not relate to specific technical skills but to general skills necessary for good

management: a team mentality, interpersonal communication skills, customer service

orientation, critical thinking ability, basic computer proficiency and role flexibility. Many

employers described that they have the ability to teach technical skills on the job, but

teaching these “people” skills represents a much greater challenge.

Many of the needed skills and competencies gleaned from interviews with employers run

parallel with those set forth in the National Health Care Skill Standards Project (NHCSSP).

The NHCSSP, funded by the U.S. Department of Education in 1996, was a collaborative effort

among health care delivery, labor and the education community to develop standards that

indicate the knowledge and skills expected of health care workers. The standards cover a core set

of skills that are essential and appropriate to all workers in health care services, as well as

addressing those skills necessary for four clusters of related occupations and functions, namely

therapeutic, diagnostic, information services and environmental services. (See Exhibit 54) Each

standard consists of three parts: (1) a brief title describing the skill area or topic covered by the

standard; (2) a general description of knowledge and skills; and (3) specific applications to

clarify or illustrate what is meant by the standards statement.126 Exhibit 54 provides a graphic model

of parts (1) and (2), showing the connections among the sets of NHCSSP standards.


THERAPEUTICCORE

Provides treatment over time

DIAGNOSTICCORE

Creates a picture ofhealth status

THERAPEUTIC-DIAGNOSTICCORE

Common skills for therapeutic& diagnostic workers

INFORMATION SERVICESCORE

Documents & processes information

ENVIRONMENTAL SERVICESCORE

Creates a therapeutic &supportive environment

HEALTH CARECORE FOUNDATION SKILLSFOR ALL HEALTH SERVICES

E X H I B I T 54: Health Care Core and Occupational Clusters

*There is a notable overlap between the knowledge and skills required for therapeutic and diagnostic functions. A set of standards applicable to both is referred to as the

Therapeutic/Diagnostic Core.

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THERAPEUTIC-DIAGNOSTICCORE

• Health Maintenance Practices • Client Interaction • Intrateam Communication • Monitoring Client Status • Client Movement

NHCSSP Standards

THERAPEUTICCORE

• Data Collection • Treatment Planning • Implementing Procedures • Client Status Evaluation

NHCSSP Standards

DIAGNOSTICCORE

• Health Maintenance Practices • Client Interaction • Intrateam Communication • Monitoring Client Status • Client Movement

NHCSSP Standards

INFORMATION SERVICESCORE

• Analysis • Abstracting and Coding • Systems Procedures • Documentation

NHCSSP Standards

ENVIRONMENTAL SERVICESCORE

• Environmental Operations • Aseptic Procedures • Resource Management

NHCSSP Standards

HEALTH CARECORE

• Academic Foundation • Communications • Systems • Employability Skills • Legal Responsibilities • Ethics • Safety Practices • Interpersonal Dynamics

NHCSSP Standards

E X H I B I T 55: National Health Care Skill Standards

Source: Reproduced from FarWest Laboratory for Educational Research and Development. National Health Care Skill Standards Project. San Francisco, CA: FarWest

Laboratory for Educational Research and Development, 1996, p. 13.


106 While Exhibits 54 and 55 present general standards and skills necessary for health care

workers, Exhibits 56 through 59 present the specific skills employers are seeking in their specific

setting, including hospitals, long-term care facilities, home health agencies and clinical

laboratories, based on the Project survey. In addition, two innovative programs that aim to

teach some of the interpersonal skills are highlighted in “Putting on the Ritz: Where Customer Service

is a Core Competency” and “Tenet HealthCare Corporations Ethics Program.” The following paragraphs

summarize the survey and interview findings of what skills employers feel are lacking in the

present health care workforce.

Ability to Work in a Team: Particularly in larger health care settings (hospitals, large

ambulatory care clinics or long-term care settings), care is being delivered in teams.

Although allied health workers are trained within individual disciplines and skill levels, the

care delivery setting asks workers to interact with providers at a number of different levels

and within different functional areas. As a result, allied and auxiliary workers (as well as

physicians) must be prepared to work in teams which they have not done in the past. Trust,

communication, delegation and a shared sense of purpose (“teamwork”) are all values and

skills that members of health care teams must possess. As one HR director in a rural facility

explained, “‘The Lone Ranger’ doesn’t succeed here.”

Communication and Interpersonal Skills: The importance of interpersonal communication

skills cannot be understated. Communication with patients, other providers and families is

a critical skill in any health care organization. Listening skills and an understanding of

different individuals’ communication styles are important for both patient interaction and

for colleague interaction as more care is delivered collaboratively in teams.

Health professions schools have not traditionally taught communication skills. Some care

delivery systems are implementing their own seminars to bolster these skills, but most of this

skill development has been coupled with reengineering efforts. As part of these restructuring

efforts, trainers lead sessions in proper communication. In one large facility in Northern

California preparing for team-based primary care practice, team members view videotaped

patient interactions and then discuss listening skills and different styles of communication.

Customer Service Orientation: Traditionally, customer service has not been a priority of the

health care industry. However, as patient satisfaction measures become increasingly valued

by health care organizations, all health care providers must demonstrate excellent customer

service. As one outpatient clinic manager explained, “Our medical assistants are our


‘Ambassadors of Care.’ They need to listen, to pay attention, to care and to make a personal

connection with each of our members.” As patient satisfaction measures are elevated in

importance among care delivery organizations, allied and auxiliary health care workers will

increasingly be evaluated (and compensated) on their service orientation.

An orientation towards customer service ranges from appropriate telephone etiquette, a

solution-oriented attitude, pleasant demeanor and general respect for customers. These

qualities, as one HR director in a Central Valley facility stated, “are hard to describe, but

you know good customer service when you experience it.”

Critical Thinking Skills: As health care roles expand in the future, critical thinking skills will

become increasingly valued. However, HR directors across the state cited a lack of critical

thinking skills for many of their workers. This need for critical thinking skills will only

intensify as providers, particularly at the highest skill levels within allied health, will be

responsible for more decision making and supervision of other providers.

For example, as Kaiser Permanente Northern California rolls out team-based adult primary

care, the roles of many providers will change dramatically. Two allied health professions,

physical therapists and medical assistants, are included in the teams and will be asked to

function in new ways. Under the new team-based model, patients with routine musculoskeletal

problems or sports injuries may see a PT for an initial assessment if that is decided to be more

efficient than seeing a primary care physician. In this new role, the physical therapist will be

asked to use his or her critical thinking skills in deciding whether the patient needs a longer

course of therapy, a single visit, or needs an appointment with a physician.

Critical thinking skills are a foundation skill of any valuable health care provider. Most employers

were hesitant to cite specific deficiencies in technical skills among job applicants and recent

graduates, and employers are prepared to teach technical skills. But they are not prepared to teach

students how to think critically, a skill that educators at all levels need to reinforce in students.

Basic Computer Proficiency: As health care systems integrate more computer-based systems to

improve efficiency, reduce cost and improve quality, basic knowledge of computers will

become essential for all employees. While many care delivery organizations have automated

billing, patient appointment or admitting systems in the hospital setting, full

computerization of medical records and associated administrative and clinical procedures

has not yet occurred. But most hospitals (and fewer long-term care facilities) are moving

towards electronic patient records. This will mean providers across all units will access all or

107




108 parts of medical records on line. As more facilities adopt and expand automation of clinical

functions, every health care provider will need to have basic computer skills.

Clerical workers in particular, whose job functions are primarily filing and transporting

of medical records, will be greatly impacted by increased automation. Among these clerical

positions, the need for computer skills cannot be understated. Within medical records, a

basic knowledge of keyboarding, word-processing and spreadsheets will be required for any

job in that area in the future.

Flexibility: Perhaps most importantly, health care employers seek workers who are willing to

be flexible about the roles and responsibilities they will take on. The most common

comment expressed among hospital HR directors and clinic administrators was that

employees must have an understanding that their jobs will change and evolve throughout

their careers in health care. Health care workers must expect from the outset that the way in

which they provide care will change over the course of their careers. An attitude of life-long

learning is necessary to adapt to changes in technology. Particularly in fields such as medical

records, where advances in information technology portend radical job changes for entire

departments, workers must be prepared for change. Fighting that change is an uphill battle.

Related to the need to accept and embrace change is the need to reskill and retrain.

As health care must look to new and innovative solutions to deliver care at appropriate cost

and quality levels, workers must be prepared to continually upgrade their skills, a

phenomenon not unique to the health care industry. Continual reskilling and training is

part of the way workers in general must function in the coming century.

While the survey found some skills unique to a particular setting (e.g., acute care

experience in hospitals) or to a particular occupation (e.g., experience in microbiology

for clinical laboratory personnel), many interpersonal and general skills are needed

across settings and personnel categories. These skills, such as team and service orientation

and basic computer skills, are not only the most fundamental, but often the most

challenging for employers to teach.


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“WHAT SKILLS ARE YOU LOOKING FOR IN CERTAIN WORKERS THAT YOU ARE UNABLE TO FIND?”Responses from HR Directors in Hospitals across California (sample size=19)

ENVIRONMENTAL SERVICE & Good Attendance

DIETARY PERSONNEL Team work

Customer service orientation

Speak/read/write in English

High school diploma

Willingness to learn

Accountability and responsibility

General housekeeping skills

Health care related experience

Good communication skills

Sanitation and food service safety habits

Dietary/Nurtrition knowledge

Food preparation and food service knowledge

DIAGNOSTIC IMAGING PERSONNEL Ultrasound, MRI, CT competence

Nuclear medicine

Mammography certification

Tumor registry experience

Multilicensure/competency

Computer literacy

IV certified

MEDICAL RECORDS PERSONNEL Knowledge of and experience in coding, including Current Procedural

Terminology (CPT)-4 coding

Health care experience

Knowledge of regulatory requirements

Medical background in anatomy, pathology and physiology

Tumor registry experience

Inpatient coding experience

NURSE AIDE/ASSISTANT Strong work ethic

Dependability

Acute care experience

Good communication skills

Computer skills

Teamwork skills

Performing procedures and giving feedback to nurses

(continued)

E X H I B I T 56: Skills Needed in Hospitals across Personnel Categories


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PHYSICAL THERAPY Understanding of external forces driving clinical practice (e.g., reimbursement)

Documentation skills

Wound care

Acute care experience

Good time management

Time management

CLINICAL LABORATORY PERSONNEL Medical Technologists Medical Lab Assistants

Abnormal hematology General experience in the lab

Microbiology Experience with analyzers

Acute care experience Experience in generalchemistry, hematology, microbiologyand phlebotomy

Computer skills

Supervisory skills

Client relations

Advanced blood bank experience

CLERICAL PERSONNEL Computer literacy/software skills

Keyboarding

Strong work ethic

Basic English grammer and spelling

Medical terminology knowledge

Organizational skills

E X H I B I T 56: ( continued from page 109)

Flexibility

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“WHAT SKILLS ARE YOU LOOKING FOR IN CERTAIN WORKERS THAT YOU ARE UNABLE TO FIND?”RESPONSES FROM DIRECTORS OF NURSING IN SNFS ACROSS CALIFORNIA (SAMPLE SIZE=15)

PHYSCIAL THERAPISTS PHYSICAL THERAPY ASSISTANTS PHYSICAL THERAPY AIDES

Documentation skills Documentation skills

Expertise in geriatrics Expertise in geriatrics Expertise in geriatrics

Wound care

Adequate management experience

Team building skills & ability to work Team building skills & ability to work with multidisciplinary team with multidisciplinary team

General competence General competence General competence

MEDICAL RECORDS PERSONNEL

Experience

Knowledge of coding

Ability to manage stress

CNAs

Competence

English language skills

Customer service skills

Rehabilitation Skills

Dementia care skills

Documentation skills

Patient transfer competence

Adherence to ADL provisions

Providing patient privacy

ENVIRONMENTAL/SUPPORT SERVICES HOUSEKEEPING PERSONNEL FOOD SERVICE PERSONNEL

English language skills English language skills

Work ethic Work ethic

Dependability Dependability

Customer service Customer service

Attention to safety Attention to safety

Knowledge of OBRA and Title 22 regulations

Flexibility

E X H I B I T 57: Skills Needed in Skilled Nursing Facilities across Personnel Categories


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E X H I B I T 58: Skills Needed in Home Health Agencies across Personnel Categories

“WHAT SKILLS ARE YOU LOOKING FOR IN CERTAIN WORKERS THAT YOU ARE UNABLE TO FIND?”RESPONSES FROM AGENCY DIRECTORS ACROSS CALIFORNIA (SAMPLE SIZE=8)

PHYSICAL THERAPISTS McKenzie certification, NDT certificationMeeting of State requirements, Documentation skills

HOME HEALTH AIDES Common sense, Communication skillsInterpersonal skills

MEDICAL RECORDS PERSONNEL Computer skills

CLERICAL PERSONNEL Computer skills, Communications skills

“WHAT SKILLS ARE YOU LOOKING FOR IN CERTAIN WORKERS THAT YOU ARE UNABLE TO FIND?”RESPONSES FROM CLINICAL LAB DIRECTORS ACROSS CALIFORNIA (SAMPLE SIZE=5)

CLINICAL LABORATORY Keyboarding skills

SCIENTISTS/TECHNOLOGISTS Advanced computer skills

Ability to troubleshoot

Address and reconcile test result discrepancies

Communication skills

Judgement and decision making skills

Flexibility

Work ethic

Writing skills

Client interaction skills

Organization skills

Multi-tasking in a high volume, fast-paced environment

Emotional and social stability

Management skills

Understand test results

Toxicology

Molecular diagnostics

Flow cytometry

Microbiology

Medical and laboratory terminology

LABORATORY ASSISTANTS Keyboarding skills, typing, data entry

Advanced computer skills

General, technical and procedural knowledge

Communication skills

Judgement and decision making skills

Flexibility

Work ethic

Writing skills

Emotional and social stability

Client interaction skills

Standard techniques

Medical and laboratory terminology

E X H I B I T 59: Skills Needed in Clinical Laboratories across Personnel Categories

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Putting On The Ritz: Where Customer Service Is A Core Competency

One surgery center in the Central Valley has elevated the importance of customer service

to make it one of the organization’s core competencies. Senior management decided to

benchmark their customer service not with other health care institutions, but with the Ritz

Carlton. The Fresno Surgery Center (FSC) sent their senior management to the Ritz

Carlton’s headquarters for training and emphasized the importance of customer service at

every level from the very first day of employment.

All new employees attend a monthly training called “Guest Relations 101”. Underscoring

its importance, FSC’s CEO attends this session monthly to explain personally how crucial

a customer service orientation is to FSC’s business. Guest Relations 101 teaches new

employees the basics of treating guests in terms of answering the phone, dealing with

conflict, and explaining how respect and attitude impact relations with guests and co-workers.

But customer service is not a concept that FSC only emphasizes with new hires.

Borrowing an idea from the Ritz-Carlton, the surgery center developed 30 standards that

help employees define what they can expect from each other and how they should interact

with their customers. One of the standards is: “Every day my attitude and performance

will be the best that it can be.”

To reinforce these standards, departments frequently meet before shifts or events for

five minutes in a “line up”. In these line ups, a standard or core competency is stressed

and information about the organization is shared. The more people know, the Fresno

Surgery Center’s believes, the more they can excel.

The Fresno Surgery Center’s philosophy of treating people well extends to their

employee because “happy employees mean happy customers,” FSC’s human resources

director explained. Their benefits package is generous, including medical, dental and

vision, but also a 401k plan with an match of up to 4 percent, and profit-sharing. Other

perks include flex time, working at home, casual dress, take home dinners, and warm

lunches for all employees. As a result, employee satisfaction is high and customers also

react favorably to the center’s quality efforts. In a 1995 customer survey, 100 percent of

the customers answered yes to the question: “I would choose Fresno again and would

recommend the Fresno Surgery Center.”


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Tenet HealthCare Corporation’s Ethics Program

The Tenet HealthCare Corporation has created an Ethics Department staffed by eleven

personnel who develop curricula and conduct training on a variety of health care,

interpersonal and work ethic skills. In addition to this training, six employees of the

Ethics Department staff answer calls on the Ethics Action Line, a confidential telephone

line that any employee may call with questions or concerns about Tenet’s policies, ethical

or compliance issues, or concerns about employees including employee-management

relations. The department has expanded the training effort and has seen an increase in

the number of calls it receives on the Action Line, increasing from approximately 100

calls per month when the program was first offered in 1993 to 646 calls in August of

1998. Across industries on a national level, such call lines on average receive calls from 3

to 5 percent of an organization’s employees, while Tenet’s numbers represent

approximately 6 percent. Tenet has developed the Action Line and ethics training

program for all of its 117,000 permanent employees working at least 24 hours a week.

The department officer and manager train 120 Tenet employees across the country,

director level and above such as CEOs and Chiefs of Nursing, to serve as facilitators who

travel to Tenet facilities and provide initial and update training to all Tenet employees.

The ethics training program is introduced to all new hires at Tenet in the new employee

orientation. Within the first four months of employment, each employee participates in a

two-hour class. The first hour of the class provides information about the corporation’s

philosophies, standards of conduct, and information about Tenet’s Human Resources,

legal responsibilities and Quality programs. The next hour involves a presentation of ten

written case studies of work situations. The class participants break out into groups that

read and discuss the case studies in terms of identifying the issues involved in the situation

and the options the involved people have to respond. After the break out groups,

participants come back together to discuss further and synthesize the information that has

been shared. While classes are facilitated by director level or higher Tenet employees, there

is a mix of personnel in each class, from environmental and support services personnel to

administrative personnel to nurses. Class participants all work at the same Tenet facility,

however facilitators are from another facility.

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The update classes are scheduled for 1 1/4 hours every year someone is an employee at

Tenet. In these classes, three case studies are presented on video around issues such as

sexual harassment, patient confidentiality and conflict management. Recently, Tenet has

created and filmed their own vignettes for these classes. They contracted with GTE-Visnet

who helped them produce their own videos working from scripts that Tenet had written.

Addressing fundamental issues in the health care industry, next year’s video case studies

will concern billing for non-reimbursed services, fraud in home health care and

preparation for an accreditation audit by the joint commission.

The ethics department at Tenet is tracking their training programs as well as the calls

they receive on their Action Line. They track attendance at both the orientation and

update sessions and this attendance is part of their performance evaluation. Participants

complete evaluations at the end of each class and the facilitators also provide reports of

each class they lead. The ethics department also reviews the annual Employee Opinion

survey to look for concerns and additional feedback on the program. They also track all

the telephone calls received. Department Manager Sandra Lawrence states that 90 percent

of the calls are made anonymously and 80 percent of callers identify the Tenet facility they

are calling from. Depending on the content of the call, investigation and appropriate

follow-up is performed. Sandra has also conducted focus groups with various facilities to

solicit feedback on the program components, particularly when they have modified the

curriculum. Through evaluations and focus groups, they learned that employees feel more

comfortable to participate when the facilitator is a senior manager from a facility other

than their own.

In addition to the training, the ethics department offers related programs such as

motivational speakers. They are finding the program to be successful and that other health

care institutions are looking to the Tenet program as a model to emulate. Informally,

Sandra talks with other care delivery institutions and provides information about the

curriculum and development of the ethics training. While Tenet considered contracting

out the training program to a national consulting firm, they have been successful in

developing and implementing the program in-house. They foresee continuing and

expanding the program in the future.

4. OUTSOURCING, SUBCONTRACTING AND TEMPORARY WORKERS

In an effort to contain labor costs and access expertise in an efficient way, U.S. industries

are making more use of contracted and temporary personnel. Health care delivery

institutions appear to use contract and contingent workers less than other industries. In the

Project survey, hospitals and skilled nursing facilities reported about ten percent of their

services are outsourced and less than five percent of their workforce is temporary. But there

is evidence that these and other non-permanent full-time employees will be utilized more

frequently in the future. To do so, however, the survey findings suggest that employers need

to more methodically measure the outcomes and performance of these workforce strategies.

Outsourcing and Subcontracting - In an annual survey of contract management companies,ee the

75 firms responding reported a 45 percent increase in the number of contracts between 1995

and 1996.127 Depending on a number of factors, health care organizations may contract out the

management of a service, the personnel, or both. Within the health care industry, the top 20

contract management firms, defined by the total number of health care clients, include

ServiceMaster, Sodexho Marriott, and ARAMARK Corporation.128 ARAMARK, a firm that

has conducted cross-industry studies, estimates that 40 percent of hospitals outsource one or

more services. In comparison, in the education field, approximately 85 percent of colleges

outsource some services, according to ARAMARK's industry analysis.

Nationally, in hospitals and long-term care facilities, the top number of contracts reported

in 1997 were in housekeeping, food and laundry services, clinical/diagnostic equipment

maintenance, pharmacy and rehabilitation/physical therapy. In some instances, specialized or

tertiary types of care, such as emergency room services or hemodialysis, are contracted out if a

hospital cannot recruit or retain full-time personnel with the appropriate expertise.

Furthermore, information or administrative services, most commonly medical billing and

transcription, are contracted out by hospitals.

While cost reduction is a main goal for many health care facilities, a growing number of

providers also aim to increase service quality.129 For these reasons, the management of

non-clinical services such as food services has become particularly important. Managers

from contract management firms offer the expertise in setting, maintaining and auditing

for service quality and regulatory standards. In addition, within services where the


116


ee. The survey, conducted by Modern Healthcare, identified over 200 contract firms that manage a widerange of services across industries on a national and international level.

117



workforce does not commonly advance to higher levels of responsibility, providing

management oversight is essential.

The types of services and reasons for outsourcing identified on the national level were

supported in the Project survey. For example, Project interviews found that non-clinical

support services, including food, housekeeping, facility maintenance and engineering, are

commonly contracted services in long-term care facilities and particularly in hospitals. The

long-term care survey revealed that clinical areas such as laboratory, pharmacy and

rehabilitation services are more often outsourced in these facilities than in hospitals.

During interviews, Human Resources Directors for both urban and rural hospitals cited

contracting out such services because of difficulty in staffing these positions and because of

evidence of cost reduction. While more information is needed on the outcomes of

outsourcing, quantitative data are usually proprietary, not consistently collected or not at all

available. Still, anecdotal and qualitative information has been described in the literature,

from experts, as well as during the industry interviews.

Hospitals in the Project survey reported the use of internal and external customer and

quality measures to assess contracted as well as other services. In addition to contract

management firms’ resources and expertise in monitoring performance, many hospitals

routinely assess patient satisfaction. These measures attempt to monitor health care

performance and the quality of food and personnel services. For example, some hospitals

reported that they measure not only patients’ satisfaction with their physician, but also

satisfaction with the nursing staff, radiology staff, rehabilitation staff and support services

staff. Other hospitals measure patient satisfaction by particular floors or units within the

hospital. And these measures can be related to contracted services. For example, one skilled

nursing facility respondent indicated that specific outcomes such as medications

administered and patient functioning are measured in relation to contracted services.

Contract Management Firms in Profile describes a few contract management firms that represent

examples of providing allied and auxiliary health services for care delivery organizations on

both national and local levels.


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Contract Management Firms in Profile

Non-clinical services

Sodexho Marriott provides management services and measurement tools to monitor and

track performance of the services. Similar to multiskilling and other reengineering efforts

occurring in hospitals, Sodexho Marriott trains ‘Patient Care Partners’ who are

crosstrained to provide an array of services such as housekeeping, laundry, patient

transport and other floor-based patient care.130 As a health system creating an integrated

care delivery system, Sharp Health Care in San Diego utilizes Marriott Health Care

Services as part of their system-wide support services; this contract was reported as the

largest of its kind in the health care industry when it was first announced at the end of

1995.131 (Retrieved from: http://www.marriott.com/. Marriott health Care Services. 100

Avon Meadow Avon, Connecticut 06001. (860)678-1023.)

ARAMARK Health Care Support Services includes food, housekeeping, and biomedical

services as well as some that cross over into patient contact services, such as patient

transport. Approximately 25 percent of ARAMARK’s business is within the health care

industry, and 10 to 15 percent of this part of the business is with California hospitals

according to Tim Hogen, Director of Marketing. Depending on the individual hospital,

ARAMARK may employ service employees in addition to the service managers.

ARAMARK focuses on in-service training for employees, defining employee roles including

rewriting job descriptions, and aligning cost and quality outcomes with those of the hospital.

ARAMARK’s INTERSERV concept is a custom management system for integrated patient

support services designed to deliver agreed upon outcomes for each of their customers.

Using this concept, ARAMARK promises reductions in service cost and improvements in patient

satisfaction. (Retrieved from: http://www.aramark.com. ARAMARK Health care Support

Services. ARAMARK Tower 1101 Market Street Philadelphia, PA 19107. (800)556-4472.)

Boston Reed in St. Helena, California provides clinical training for medical assistants,

phlebotomists, EKG technicians and orthopedic technicians. Boston Reed hires

phlebotomists, technicians and medical assistants on a part-time contract basis as

instructors. Instructors provide didactic and clinical training as well as evaluation of

training to Boston Reed clients. One of their clients, Kaiser Permanente has contracted

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(continue from page 118)

their services to train medical assistants in patient assessment and care tasks including vital

signs, adult ear washes, respiratory and inhalation therapy, glucose testing and wound

care. Training is provided on-site at several Kaiser facilities and is customized to each

facility’s needs. The training includes demonstrations and written tests as well as training

Kaiser Permanente staff to be preceptors to carry out additional training and monitoring.

Clinical services

Therapist’s Choice, a small contract firm, places licensed physical therapists,

occupational therapists and speech therapists as well as therapy assistants. Therapist’s

Choice matches therapists with clients and then therapists interview with the client to

determine final placement. Therapist’s Choice provides some training, such as training in

Medicare reimbursement, however, much of the training is conducted on-site at the

hospital, skilled nursing facility or outpatient facility. Employees of Therapist’s Choice

receive some medical and other benefits. (Retrieved from: http://www.thch.com.

Therapist’s Choice. 1180 Medical Court, Suite C Carmel, Indiana 46032. (317)846-6304.)

Comprehensive Pharmacy Services, a division of ServiceMaster, employs pharmacists

and pharmacy technicians to provide services to hospitals, long-term care facilities and

correctional facilities. Pharmacists and pharmacy technicians receive job-related training

from Comprehensive Pharmacy Services as well as benefits. Comprehensive Pharmacy

Services sees a willingness to outsource among health care employers, particularly since it

is an efficient method for health care facilities to control cost. The firm maintains

continuous contact with their clients by conducting their own site visits as well as receiving

client’s internal evaluation of pharmacy services. (Retrieved from: http://www.cpspharm.com.

Comprehensive Pharmacy Services. 3246 Players Club Circle Memphis, TN 38125.

(800)968-6992.)


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Employing Contingent Workers - The use of contingent workers can allow for a flexible

workforce that is needed in a competitive market. Across industries, research studies

have found that contingent workers are utilized not only to contain costs, but also as a

competitive strategy by management.132 The temporary workforce can meet the “non-core

competency” needs of a business and the flexibility is often an advantage for the employer.

From the employee perspective, advantages include additional income, flexibility, learning

new skills and balancing work with other parts of their lives.

The contingent workforce includes workers who are temporary part-time, registry,

‘traveling’ and per diem. The size of the contingent workforce is estimated to be 2 to 19

million, or 2 to 16 percent of the total workforce. There is evidence that these numbers are

increasing, especially in the personnel-supply services industries.133 However, many people

who work on a temporary basis have the goal of finding a full-time position with benefits.134

Still, while some workers do want permanent, full-time positions with benefits, other

workers, who may receive benefits from a spouse or second job, or who need the flexibility

to balance work with other parts of their lives, desire the flexibility of part-time work.

The Project survey found that the level of supplemental staffing used on any given day

ranged from “Less than 5 percent” to “Less than 10 percent” of the total workforce,

including nursing personnel. Respondents reported that some contingent workers had

second jobs. Furthermore, employers reported that they contract some personnel to work

part-time or on-call, and that they do not include these workers in the estimate of their

contingent workforce. Thus, the percentage of the temporary or non-full time, permanent

workforce may actually be higher.

While temporary employees do not receive benefits, the differential pay in hourly wages

attracts personnel to these positions. Across industries, the standard pay differential is

approximately 20 percent. Survey respondents estimated that between 10 to 20 percent or

1 to 2 dollars more per hour is offered to contingent workers.

In the health care industry, the use of temporary staffing occurs predominantly in

nursing. In addition to nursing personnel, health care-oriented temporary agencies place

rehabilitative therapists, as well as medical assistants, technicians, and many clerical

personnel. These agencies vary in the quality assurance and benefits provided to their

employer and employee clients respectively. Typically, agencies perform extensive interviews

with personnel to ensure qualifications; they also may monitor their placements with

interviews and in-service visits. In addition, some supplemental staffing agencies offer

varying amounts of benefits. One temporary agency that places diagnostic imaging and

clinical laboratory personnel, RAPID TEMPS covers worker’s compensation during the

placement and continuous competitive benefits.135

There are significant regulatory and quality standards that must be addressed with temporary

staffing for the health care industry. Therefore, employers often exhaust internal registries

before turning to external sources. With internal registries, the employer has more control

over quality standards, and the personnel are more familiar with the systems and the facility.

One example of a facility using an internal registry is Kaiser Permanente’s internal

supplemental staffing agency that began with nursing and now includes allied health care

workers. Called The Network, Kaiser Permanente’s temporary agency requires personnel to

commit to filling a minimum of 12 shifts every 2 to 3 months. These workers do not receive

benefits, and their skills are validated on a routine basis to ensure quality. Kaiser Permanente

describes that personnel move between permanent positions and The Network depending on

their current needs. Kaiser Permanente reported that The Network reduces the cost of

supplemental staffing. Furthermore, The Network personnel demonstrate a higher level of

commitment to the organization than personnel from an outside agency would demonstrate.

5. CHANGING CAREER EXPECTATIONS

Allied and auxiliary health care workers employ a wide variety of skills and educational levels,

ranging from the aide/assistant level to the technician and professional levels. These

correspond with various educational pathways, ranging from on-the-job training (OJT) to

associate, bachelors, masters and doctoral level training. This variety of skill and educational

attainment levels, in theory, creates a number of career advancement opportunities for this

segment of the workforce. But the nature of the career ladder is changing. In the past,

employees expected automatic career advancement earned through length of work service.

Today, employers expect workers to take initiative for their own career progress.

As a result, individual commitment to continuing education and seizing promotion

opportunities has become as important as formal education or OJT in determining a

career path. Particularly for low skilled or entry-level workers, advancement mainly

comes by exiting a place of employment and pursuing new credentials through a formal

educational program. Thus, the availability of affordable evening courses offered in

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122 convenient locations becomes an important factor in career advancement. Additionally,

the availability of articulated educational programs, that is, those that recognize prior

coursework and experience, for those looking to move from a certificate to associate

degree, or move from an associate to bachelors degree or higher, are important factors as

well. However, unlike nursing education, the allied health educational system has been

criticized for not responding with programs that advance allied health professionals from

technician to professional levels, or assistant to technician levels, without repeating

former coursework.136

The Project’s survey of employers found that only a small percentage of allied and auxiliary

workers advance to higher jobs within the hospital setting. Additionally, when questioned,

human resource directors were more likely to cite examples of career mobility for their

nursing staff rather than for allied or auxiliary workers. At the hospital level, this lack of

career advancement exists despite the fact that the vast majority of hospitals offer some type

of educational assistance for its employees, ranging from tuition reimbursement to release

time, or in some instances, paid time off.

Hospital HR directors cited the least career mobility among entry-level workers such as

nurse aides and assistants and clerical support personnel. For nurse aides and assistants,

there was very limited advancement as well as very high turnover. Generally, entry-level

clerical advancement was limited to advancing into a more supervisory position or another

clerical position. Examples included movement to billing or a ‘more technical area,’ such as

medical/surgery or operating room scheduling. In some facilities, a small number of clerical

employees advanced to clinical positions, but this was the exception rather than general

practice. Of the surveyed hospitals, a majority stated that less than 25 percent of nurse aides

and assistants and clerical support personnel advance. Some hospitals stated that there was

absolutely no career advancement while a few stated that 25 to 50 percent advance.

Similarly, a few long-term care survey respondents stated that there is no advancement for

CNAs while most stated that less than 25 percent of their CNAs advance. Across the home

health agency sample, the respondents also reported that there was very little advancement

of allied and auxiliary workers.

There appears to be slightly more room for advancement at the entry-level clinical and

clerical levels in rural hospitals than in urban hospitals. For example, one small non-profit

hospital in the Central Valley promotes more than half of its clerical staff into more


advanced administrative or clerical positions over time. At that facility, the HR director had

started as the receptionist 15 years earlier. Possible reasons for greater promotion in rural

facilities may be related to their inability to recruit from a larger labor pool, lower rates of

turnover in these areas, and the necessity of upskilling most employees due to lower volume

and budget constraints.

Educational Assistance Programs - The majority of hospitals surveyed offers some type of

educational assistance benefit for employees. However, during the Project’s interviews, the

question of support for education in pursuit of a further degree or certification was often

confused with support for required continuing education units. Most often, employers do

not offer support for taking individual classes to develop specific skills, or this support is on

an individual basis rather than a standard employee program. Both small and large hospitals

offer tuition reimbursement and unpaid time off work to support employees who enter

formal allied health educational programs. Four from the sample of larger hospitals are able

to offer paid time off work for this educational assistance. Hospital educational assistance

benefits are comparable to those offered by long-term care facilities.

Among the 15 long-term care facility respondents, 11 offer tuition reimbursement, four

provide unpaid time off, and one offers paid time off. This contrasts with home health

agencies and clinical labs that do not provide equally generous benefits for educational

assistance. In the home health agency sample, the most common form of assistance is unpaid

time off. A few respondents offer paid time off for necessary staff members to attend

educational seminars. As for the clinical laboratory sample, two of the five indicated that no

educational assistance is provided, and the other three offer tuition reimbursement.

Furthermore, only one of the five labs reported that the continuing education units that are

required for the clinical laboratory scientist were paid for by the lab.

Despite the high percentage of hospitals and long-term facilities offering some type of

educational assistance, the majority of respondents stated that less than ten percent of their

employees took advantage of these programs. Of those employees that do utilize educational

assistance benefits, the majority of them were nurses. Among the clinical laboratory

respondents, labs reported that less than five percent of the personnel take advantage of the

tuition reimbursement if it is offered, citing that most personnel are not interested. One

lab offering educational assistance indicated that mostly administrative (non-laboratory)

personnel take advantage of their program.

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124 At those hospitals with particularly generous educational assistance, for example, offering

paid time off, a greater number of employees took advantage of the benefit. For example, at

one 285 bed facility in the Central Valley that offers paid time off in addition to tuition

reimbursement, 10 to 25 percent of their employees use the program.

Although employees must ‘pay back’ their paid time off in equal service to the institution after

the program is completed, the facility’s benefit is more generous than most other hospitals. As the

hospital’s HR director stated, “our best physical therapy assistants (PTAs) are present employees

who start out as PT aides and use our educational assistance program to become PTAs.”

Additionally, some of its clerical staff have also advanced to clinical positions such as RN, LVN or

Radiology Technician, though this is less common than advancement within the clinical areas.

Part of the motivation to provide such a generous educational benefit may exist because of

this facility’s location. Bordering on a rural area, their ability to recruit providers is more

difficult than their urban counterparts. Thus, the educational assistance program may

counterbalance that difficulty.

6. PRESSURE ON BENEFITS AND WAGES

Given the current trend to reduce health care delivery system expenditures and the staggering

costs associated with providing benefits, employee benefits would seem a likely target for cost

reduction efforts. Yet, with the exception of home health agencies, many of the institutions

interviewed are continuing to provide generous benefit packages to their workforce. In some

settings, however, employees are responsible for paying a high premium in order to receive

health, vision and/or dental coverage. Benefit packages range from health, dental and vision

coverage (with or without premiums) to paid time off, short- and long-term disability and

life insurance. In some instances, profit sharing and 401K plans are also offered.

Several impediments to reducing benefits currently exist.ff First, unionization of many health

care workers presents a significant challenge to reducing benefits. County and government-owned


ff. The majority of the information presented in the following section is taken from the Project’s qualitativeinterviews with the four different care delivery settings. In addition, information is presented from theCalifornia Medical Practice Employee Salary Survey, a report by the Medical Group ManagementAssociation (MGMA), and the 1996 Survey of Wages and Benefits, the first joint report on wages and benefitsof employees in long-term care facilities from the California Association of Homes and Services for theAging (CAHSA) and the California Association of Health Facilities (CAHF). For this survey, CAHSAand CAHF invited all of their members to participate, and a total of 324 participated. Data available inJune to July 1996 from the participating facilities were collected, and the data presented below are fromskilled nursing facilities that represent more than one-third of the facilities reporting to the survey.

institutions also face significant bureaucratic hurdles in reducing benefits or compensation for

their employees. Finally, to continue with a hospital culture that has historically valued the

provision of generous benefits will pose serious challenges to reducing benefits. While these are

daunting challenges, so too are the cost pressures that institutions face.

Despite these impediments, one way employers reduce or eliminate benefits is by offering

permanent part-time positions that pay a wage differential. Some institutions interviewed

suggested that in the future they are looking to expand their permanent part-time workforce

to eliminate benefit expenses. However, most offer some type of benefit package for part-

time workers. Interestingly, others cited a movement to more permanent, part-time

positions as a response to worker demands for flexible schedules rather than cost pressures.

Many hospitals facing shortages cited part-time employment, particularly in technical areas,

as a perk rather than as an undesirable position.

Differences in Benefits among Health Care Settings - Among the four care delivery settings the

Project interviewed, hospitals tended to offer the most generous benefit packages to all levels

of employees. The minimum number of hours that must be worked in order to be eligible

for benefits ranged from 16 to 36 hours. Most of the smaller hospitals indicated that 50 to

75 percent of their staff are eligible for benefits, and the larger hospitals are more likely to

have 75 percent or more of their workforce eligible for benefits.

A literature review suggests that employees in skilled nursing facilities receive less

compensation (wages and benefits) than their counterparts in other health care settings.

However, the interviews revealed that within institutions where a skilled nursing facility is

associated with a hospital, employees in both care delivery sites receive the same wage and

benefits package whether or not they are shared between settings.

Among the respondents to a 1996 survey,gg almost all long-term care facilities provide

one or more benefit plans. Facilities typically reported that new employees are eligible to

participate in these plans following two or three months of work. For the skilled nursing

facilities responding, 5 percent provide a basic hospitalization/medical/surgical plan, 62

percent provide comprehensive major medical insurance, 79 percent offer the Preferred

Provider Organization (PPO) plan, 61 percent provide the Point-of-Service (POS) plan,

58 percent offer an Individual Practice Association (IPA) plan, and 97 percent provide

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gg. Based on the 1996 Survey of Wages and Benefits joint report of long-term care employees.


126

access to an HMO. With the exception of the basic hospitalization/medical/surgical plan,

the monthly cost of these plans for the employee, for three levels of coverage, is presented

in Exhibit 61. Exhibit 62 provides additional costs to the employee for dental and vision care.

According to these data for long-term care facilities in California, even though wages

for allied and auxiliary workers are low (see Exhibit 60), workers continue to have to pay a

large portion of the premium in order to obtain benefits (see Exhibits 61 and 62). The high

premium expense makes it difficult for employees who receive a low wage to afford

benefits despite the fact that the employer may offer this option.

For home health agencies, a reduction in benefits was reported by interview participants.

Most survey participants reported that they have recently decreased benefit options for their

employees due to the impact of Medicare’s Interim Payment System (IPS). Also, as stated

above, many agencies have switched their staff to a per diem status, and, therefore, these staff

members are not eligible to receive benefits. One agency reported that they have had to

eliminate benefits for all employees, including full-time staff.

Of the small sample of clinical laboratories interviewed, the benefits offered appear to be

generous. No changes in benefit levels were reported. The minimum number of hours

required to be eligible for benefits on average was 30. With the exception of one lab, more

than 75 percent of employees were reported as eligible to receive benefits.

Allied and auxiliary workers in medical offices, similar to long-term care, continue to pay high

premiums for their health insurance. According to California Medical Practice Employee Salary Survey, in

medical groups 97 percent of respondents offer medical insurance to their employees. Of that

group, almost three-fourths pay 100 percent of the insurance premium, so the employees do

not share the cost. However, less than ten percent pay fully for dependents’ insurance.137


E X H I B I T 60: Average Wages for Select Allied and Auxiliary Personnel in California Long-Term Care Facilities, 1996

PERSONNEL CATEGORIES

CNA Restorative Aide Diet Technician Cook II Housekeeper

Average starting rate 5.95 6.76 n/a 6.62 5.22

Average hourly rate 6.92 7.66 6.14 7.83 6.38

(no. of facilities (n=119) (n=40) (n=68) (n=94) (n=116)reporting)

Source: The California Association of Home and Services for the Aging and the California Association of Health Facilities. 1996 Survey of Wages and Benefits. Sacramento,

CA: California Association of Homes and Services for the Aging and the California Association of Health Facilities, 1996.

Control on wages - Wage rates are another target for cost control efforts by the care delivery

industry. Similar to benefit levels, wage rates for the allied and auxiliary health care

workforce are generally high, however, there are important patterns and exceptions to

acknowledge. While wages for many allied and auxiliary occupations and professions are

relatively high, wages for some occupations and professions fall below those of comparable

occupations. Furthermore, during the past decade, while wage rates for some occupations

in this workforce have kept pace or exceeded the rate of inflation, for others, wage rates have

increased well below this rate. The following conclusions are drawn from the wage data

presented in Section IVD.

Many allied and auxiliary professions and occupations earn higher wage rates than similar

occupations in other industries with the exception of the computer/technology industry.

For example, cleaning and building service occupations in health care earn higher wages

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E X H I B I T 61: Employee Average Monthly Cost and Percent of Total Cost for Health Care Workers in Long-Term Care Facilities in California, 1996

COMPREHENSIVE MAJORMEDICAL INSURANCE

Employee only $60 (23.5%) $65 (43.3%) $69 (47.9)

Employee + 1 $186 (39.3%) $192 (67.6%) $212 (73.3%)

Family $258 (40.8%) $294 (71.9%) $327 (79.8)

EXHIBIT 62: Average Monthly Costs for Dental and Vision Care for Employees of Long-Term Care Facilities in California, 1996

DENTAL CARE COST VISION CARE COST*

Employee only $23 $5

Employee + 1 $40 $10

Family $60 $15

PPO/POS PLANS HMO/IPA PLANS

Source: The California Association of Home and Services for the Aging and the California Association of Health Facilities. 1996 Survey of Wages and Benefits. Sacramento, CA:

California Association of Homes and Services for the Aging and the California Association of Health Facilities, 1996. Analysis provded by Center for the Health Professions.

*Only five to six SNFs responded to this question.

Source: The California Association of Home and Services for the Aging and the California Association of Health Facilities. 1996 Survey of Wages and Benefits. Sacramento,

CA: California Association of Homes and Services for the Aging and the California Association of Health Facilities, 1996. Analysis provded by Center for the Health Professions.


128 than those occupations in the personal services and retail trade industries. In addition,

health and nursing aides, food preparation and services occupations and personal

attendant/service occupations within health care earn higher wages than those occupations

in all other private industries on average.

Similarly, among entry-level occupations, wages for nursing occupations, therapists and

health technologists/technicians in health care reflect a higher return on educational

investment compared to some comparable occupations and education levels outside of

health care. However, many occupations outside of the health care industry at the graduate

degree level earn higher wages. This reflects a greater return on educational investment for

non-health care occupations than health care occupations requiring the same level of

education such as nursing, therapists and health technologists.

Over the past decade, wages for some allied health occupations such as physical therapists,

therapists, radiologic technicians, health technologists/technicians and dental assistants have

kept pace or exceeded the rate of inflation. However, for other allied and auxiliary

occupations, including dietitians, health technologists/technicians n.e.c., clinical lab

technologists/technicians, nursing aides and health aides, median weekly earnings increased

well below the rate of inflation. The stability of inflation-adjusted wages for the allied and

auxiliary workforce implies a control of wages. Moreover, some declines in adjusted wages seen

in the past five years may be a significant part of the strategy to contain cost by care delivery.

7. THE CHANGING ROLE OF UNIONS

The role of organized labor is changing significantly, both in the types of members

unions are seeking to represent as well as the relationships they are striking with industry

partners. The organizing drive by SEIU Local 434B described in Landmark Labor Drive For

Home Care Workers in Southern California highlights the shift in labors’ focus toward the service

sector (wherein most workers are located) since the dispersal of U.S. manufacturing jobs

throughout the world. In addition to this shift in membership focus, many unions and

health care employers are also striking collaborative partnerships, recognizing that

success in the changing health care environment requires cooperation and trust among

both parties. While these partnerships are creating unprecedented successes among

participants, significant tensions still exist among the majority of employers and

unionized labor.


Unionization continues to be a strategy for improving working conditions, maintaining jobs

and increasing wages. For example, after the change in legislation described in Landmark Labor Drive

For Home Care Workers in Southern California, San Francisco County and San Mateo County home-care

workers saw an increase from $5.75 to $7.00 an hour when they unionized just a few years ago.

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Landmark Labor Drive For Home Care Workers in Southern California

In February 1999, SEIU’s Local 434B won a pivotal organizing campaign to represent 74,000

Los Angeles County home-care workers,hh with 16,250 votes for the union and 1,925 against.138

As a result of the largest union membership drive since 1937, SEIU now represents the majority

of the nearly 200,000 in-home-supportive-services (IHSS) health care workers in California.ii

The unionization campaign was unique in its size and duration; it took more than 11

years and required the California Legislature to enact a law permitting home-care workers

to unionize. In 1987, state courts ruled that home-care workers were independent contractors

without the right to unionize. Although a combination of federal, state and county funds

covered their salaries, the courts ruled that neither the state nor the county was their

employer. Rather, the individual clients who hired them were considered their employer.139

In 1992, SEIU persuaded the state legislature to pass a law that authorized counties to

create an authority that would serve as the official employer of the home-care workers. Los

Angeles set up such an authority in 1997, a consumer-dominated body called the Personal

Assistance Services Council. Only then could the workers vote to unionize and participate

in collective bargaining to seek higher wages, health insurance and paid vacations.

Currently, home-care workers in Los Angeles County earn the minimum wage of $5.75 an

hour. With an estimated 45,000 to 50,000 home-care workers joining, SEIU’s next step will

be to persuade the Legislature and the governor to budget millions of dollars for home care so

that Los Angeles County can raise the wages by $1 an hour. After that, efforts will be made to

organize workers in other Southern California as well as Central Valley counties.

hh. Home-care workers are different from home health aides; home-care workers do not need state certificationto work, and they provide social, rather than health, care to the elderly or disabled. Some of their servicesinclude bathing, grooming, cooking, feeding and cleaning for the patient.

ii. Based on a phone interview with Charlie Ridgell, Director of the Home-Care Division at SEIU Local 250 onMarch 18, 1999.


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A New Future for Health Care Labor-Management Relations

Baldwin Park: The Partnership in Practice

Kaiser Permanente opened its Baldwin Park inpatient facility in October, 1998 in

record speed by using new processes that lead to greater efficiency, reduced turnover,

fewer employee grievances and improved morale among workers. As a result of a

national labor management partnership, Kaiser Permanente was able to create the

hospital from the ground up by involving all of its union partners from the start.

Using a consensus decision-making model, labor and management came to agreement

on everything from equipment ordering to unit structures, worker grievance

procedures and work teams.

(continue)

Yet, the viability of unions and industry will be threatened as both sides continue to approach

workforce issues from different perspectives, with tremendous gaps in understanding. As a result,

some organizations have begun to develop collaborative partnerships to ensure that the needs of

both the institution and the worker are met as cost pressures dictate the restructuring of jobs, the

upgrading of skills and other changes in the changing health care work environment. Some care

delivery institutions have representatives from local labor unions on their quality assurance team

or make efforts to involve a union contact when developing worker policies and guidelines and

the opening of new facilities. (See A New Future for Health Care Labor-Management Relations)

Despite the presence of labor-management partnerships, a number of tensions still exist

between employers and unions. Unions want higher wages for the least skilled workers,

compensation for additional skills and job duties, and greater input in creating new work

functions. Industry wants greater linkage between pay and performance, improved

productivity, and a more open-minded attitude among workers towards change.

Understanding and compromise on both sides will be necessary in these fundamental

areas before real change can occur. Beyond compromise, both groups will need to value

longer term planning to reposition the workforce. Job preservation in this dynamic

environment may not be possible. Therefore, it will be the responsibility of the unions to

collaboratively work with industry to reposition the workforce, particularly at the lowest skill

levels, and to retrain workers for the new jobs of the twenty-first century.

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With both parties navigating the uncharted waters of shared governance and leadership,

the partnership has not always been easy, but many of Baldwin Park’s successes point to a

new future for labor-management relations in health care. The inclusive process used to

create this hospital, the new teams and structures designed as a result of that process, and

the challenges that Baldwin Park still faces are described below.

Brief History of Baldwin Park and The National Labor Partnership

In 1994, Kaiser Permanente built the Baldwin Park medical center and a 230-bed

inpatient facility. While the outpatient center was opened, the hospital portion sat empty

for five years until a surge in membership created an immediate demand for inpatient beds.

Two years before, Kaiser Permanente and AFL-CIO acknowledged that both parties’

success in the new health care environment rested on cooperation. Twenty six AFL-CIO

unions, representing 61 percent of Kaiser’s national non-physician workforce140 signed on

to the agreement, creating a landmark pact for health care labor relations. While workers

in both organizations felt that it was commendable for Kaiser Permanente’s CEO David

Lawrence and AFL-CIO’s President John Sweeney to create such a partnership, they felt

that the challenge of the partnership lay in its application at the local level. The opening

of Baldwin Park presented such a test.

A New Way to Design A Hospital

The process used to open Baldwin Park was completely new to both labor and management.

A 20-person steering committee with equal representation from management and the signatory

unions in the national partnership (SEIU Locals 399 and 535, UNAC and UFCW) was created

and charged with making all decisions related to the opening of the facility on a consensus basis.

Rather than only having top leadership make decisions, the steering committee asked an

unprecedented number of employees to help create a better hospital. Throughout

“Blitz Week,” over 150 employees and managers (both union and non-union) broke into

small groups that were charged with providing the steering committee with recommendations

on how the new hospital should be structured. Though participants felt skeptical of

such an undertaking at first, many found that it was the first time that they understood

(continue)


why and how other departments did things. With honest discussion, people began to

“put themselves in other people’s shoes” and the work of creating new systems

and structures began.141

The steering committee also looked outside health care for ways to improve old processes.

They visited Saturn and Nabisco to see how those companies had created successful labor-

management partnerships.

As a result of these efforts, the Baldwin Park facility is distinguished not only from

other Kaiser Permanente facilities, but also from other hospitals nationally. Most of these

differences lie in the shared governance approach that was adopted. Baldwin Park is

perhaps the only facility in which a team of a union and non-union worker leads each

department with equal authority. These “self-directed work teams” are led by a

pair of “team coordinators”. Each pair of team coordinators receives two to three weeks

of training in leadership skills that ultimately allows them to transfer their knowledge to

the rest of their work team.

Successes and Challenges for the Future

Kaiser Permanente is in the process of collecting data to evaluate the new facility’s successes

and failures. Only six months after opening, preliminary successes and challenges stand out.

First, Baldwin Park opened in a record 8 months, while other hospitals take between 18

to 24 months. The facility’s timely opening helped Kaiser Permanente deal with a difficult

flu season without having to contract out beds, and the facility boasts impressive statistics.

A turnaround of 15 minutes for operating rooms at Baldwin Park compares to 45

minutes at other Kaiser Permanente facilities.142 Union and management leaders also

cite extremely reduced or almost non-existent employee grievances as a positive

outcome of the partnership. “Issue resolution” as it is termed at Baldwin Park, is a

joint process between union and management that focuses on solving issues rather

than isolating individual behavior. SEIU Local 399 also credits this process and the

partnership with improving morale among workers and reducing absenteeism.

While some of these early successes are laudable, a number of challenges still exist for the

partnership and the related success of the facility. First, some critics feel that while the process

(continue)


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that the partnership used was right, the hasty approach left some questions unanswered

and many of the team coordinators without enough training. Many of the union team

coordinators, in their first leadership position, are feeling somewhat confused about their

roles, responsibilities and boundaries of authority.

To acknowledge, the 850 employees at Baldwin Park, weary of previous failures and

accustomed to the old mode of “management acts, labor reacts,” have not adopted all of

the new systems and approaches. Both parties concede it has taken more effort to keep

teams together than initially thought. Culture changes of this magnitude do not happen

overnight, and the success of the partnership does require total commitment on both

sides. As Charles Saulsberry, Business Representative at Local 399 stated, “I really hope

that the partnership succeeds. Because if Baldwin Park doesn’t succeed, Kaiser Permanente

won’t succeed, and that means that my workers will be out of jobs. We’re intimately

tied together in this process.”

B. T H E W O R K E R S ’ P E R S P E C T I V E : F O C U S G R O U P R E S U LT S

While changes are occurring rapidly in the care delivery system, as described in Sections II

and III of this report, little attention has focused on the employee’s view of the health care

system. To present the employee’s view, a survey of recent graduates was administered,

obtaining information on the employment experiences of workers. To explore further this

view, the Project commissioned two focus groups with workers from a variety of allied and

auxiliary health care professions and occupations who are employed in San Francisco Bay

Area hospitals. One group has limited patient contact while the other group has significant

patient contact in their occupational duties. The worker’s perspective on some of these

changes underway in health care is presented. This perspective is presented in conjunction

with the pressures and rationale for employers to reengineer and transfer work among

providers described earlier in this section.

Recent Graduates from Allied Health Programs Survey - Summary

In January 1999, the Project Team at Charles Drew University conducted a qualitative

survey of recent graduates from several California allied health institutions regarding their

views on the adequacy of their allied health education. Of the approximately 3,000 mail-

in surveys distributed to recent graduates from ten allied health institutions, 318

responses were received. Some of the more relevant survey results are described below.

Based on a survey question regarding employment prior to pursuing education in

an allied health field, approximately half of the respondents indicated that they had

worked in a health field. As for employment after graduation, hospital employment

represented the majority of the career choices of the recent graduates. For example,

more than 40 percent of respondents indicated that their first job setting as an allied

health professional was in an acute care setting. Some other settings indicated were long-

term care, primary care clinics and physician offices.

When asked about the level of academic preparation, approximately a quarter of the

respondents indicated that they were “very well prepared” for their first job. More than

40 percent reported they were “well prepared”, while another quarter reported they

were “somewhat prepared.” Almost five percent of the respondents indicated they were

either “not well prepared” or “unprepared” for their first employment opportunity

following completion of their allied health training.

Over a quarter of respondents indicated that they were bilingual. Spanish and

Tagalog were the most frequent other languages spoken. Only a small percentage,

approximately 14 percent, of those bilingual respondents indicated that they were

compensated for applying their bilingual skills on the job.

When asked to recommend additional non-clinical skills for allied health

institutions to teach, the respondents indicated the following in order of priority:

computer literacy, interpersonal skills, data and information system management,

stress management and systems perspectives.

Finally, when asked if they would choose the same allied health career again, knowing

what they currently know about the field, 69 percent of the respondents indicated yes, 12

percent responded no and 19 percent were uncertain.


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135



The purpose of the worker focus groups was to explore health care workers’ attitudes

toward key career and employment issues and provide qualitative findings. (The methods

for conducting the focus groups and demographics of the participants are presented in

Appendix A.) Overall, the focus groups found that workers have some satisfaction with their

jobs, but generally feel that health care service is changing in negative ways and is a less

attractive profession in which to work. Moreover, while employers offer some training

opportunities and flexible schedules that workers appreciate, employer’s approaches to

staffing such as reengineering and multiskilling are met by workers with skepticism. Some

workers conveyed thoughtful critiques of the changes in health care, both as they affect

the workers in their jobs and also more broadly, as they affect patients and the

community. Five central observations were made during these two focus groups which are

described in detail below.

First, respondents described that they are somewhat satisfied with their jobs, despite

numerous and increasing sources of frustration. In both groups, respondents were able to

pinpoint aspects of their jobs that they like very much, and the majority of individuals in

each group said that they are fairly well satisfied with their jobs. Yet, even those individuals

who are relatively happy with their jobs feel that employment in the health care field is less

attractive today than it once was, due mainly to the pressures of managed care. Not only are

their jobs more difficult now, but some expressed concern about the quality of care provided

to patients. As one respondent remarked, “health care is going to hell in a hand basket.”

Although somewhat satisfied, focus group members identified a number of aspects of their

jobs that they do not like. When asked to predict what the next year might bring, many

individuals said that the things they dislike about their jobs are likely to get worse, rather

than better. Among the anticipated changes were:

• Greater workloads

• More paperwork

• Continued push to get patients out of the hospital faster

• Pay scales continuing to slip behind Bay Area norms

• More automation, causing people to lose their jobs

• Possible elimination of a respondent’s position

1. TARGETS FOR CHANGE

When asked what they would like to see change in their jobs during the next year, respondents

offered few substantive suggestions, indicating that they do not see easy solutions to the

problems they raised. Among the thoughts about what could be changed were:

• Provide clearer communications to patients, who do not always speak English as a first language,

• Manage the staff more efficiently and strictly, like a Veterans Administration hospital,

• Identify opportunities to provide better patient care-not just to save money,

• Reallocate funds to staff salaries, instead of remodeling the administrative suite, and

• Standardize the pay for a specific job, instead of the current different rates for union

versus non-union and full-time versus per-diem workers.

2. INCREASED WORKLOAD

The second observation from the focus groups was that there is too much work for the time

available and the pay provided for these workers. The major complaint heard in both focus

groups was the increasing workload borne by hospital employees, as cost pressures reduce

staffing levels. Some of the results of the heavy workload are: difficulty taking scheduled

breaks; concerns about patient and staff safety; not being able to take all of one’s earned

vacation time; and friction between departments as each blames the other for things not done.

Given that most focus group members indicated that they are working harder today than ever

before, a number are frustrated that their salaries have not kept pace with Bay Area costs or

with incomes in other fields. While participants seem to understand why these conditions

exist, they have few suggestions for improving an increasingly difficult situation.

3. NEED FOR EMPOWERMENT

In general, respondents indicated they do not feel sufficiently empowered to change the things

they do not like about their jobs. Focus group participants appeared to have little recourse, when

they are unhappy with a particular aspect of their job. The major course of action in such a

situation is complaining to co-workers or friends, rather than attempting to address the

problem more directly. In the few instances when individuals sought resolution to a workplace

problem, most reported having had little success. Respondents seem not to blame their

immediate supervisors for this situation, but instead, place the blame on hospital administration

or the health care system in general.

t he h idden he a lth ca re workf orce

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E X H I B I T 63: Rating of Job Features (where 1=very important, 5=not very important)

LIMITED PATIENT CONTACT SIGNIFICANT PATIENT CONTACT

Earning more money 1.1 1.7

Getting support for continuing education 1.5 1.5

Working regular Monday-Friday, daytime schedule 1.8 2.1

Getting more vacition time 1.9 2.5

Working flexible schedule 2.4 2.3

Working fewer days/week, for same total hours &pay 2.4 3.0

Being promoted to higher-level position 3.0 2.7

Working more hours per week, for more pay 2.7 3.4

Working fewer hours/week, even if pay is lower 3.0 3.7

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4. PAY VERSUS OTHER PRIORITIES

Another observation was that earning more money is important to nearly all focus group

participants, whereas being promoted is of far less importance. Of nine job aspects

individuals were asked to evaluate in terms of importance to them personally, earning more

money received the highest overall rating. The nine features are listed in Exhibit 63 with the

respective ratings. As the exhibit shows, other aspects also viewed as important included:

getting more vacation time; getting support for continuing education; and working a

regular Monday through Friday, daytime schedule. The least important of the nine aspects

were: being promoted to a higher-level position; working fewer hours per week for lower

pay; working fewer days per week for the same hours and pay; and working more hours per

week for more pay. Thus, it appears that respondents place greater value on being rewarded

more handsomely for doing their current jobs than on having their existing responsibilities

or schedules changed in any way.

And the final observation from the two focus groups was that respondents like the

notions of career ladders and flexible work schedules, but are skeptical of multiskilling

and reengineering. The concepts of career mobility and career ladders were well

received by respondents, who believe that opportunities for advancement (or lateral

moves) are positive, even if they personally may not take advantage of them. Similarly, a

flexible work schedule is an appealing notion, suggesting responsiveness to employees’

needs and preferences. A number of group members currently work non-traditional

schedules and shifts.


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By contrast, the terms multiskilling and reengineering were greeted with skepticism and

even derision by both focus groups. Multiskilling is viewed as another term for increasing

workloads and responsibilities without a commensurate increase in pay or job title.

Reengineering is perceived by those familiar with it as a department restructuring to

facilitate staffing reductions and at the expense of patient care. Individuals who have had

experience with multiskilling or reengineering tend to feel that these concepts were

implemented by senior management, without regard to the wishes of employees.

To assess workers’ perspectives on these responses or strategies from care delivery

employers, the focus group participants were asked their reactions to several workplace

concepts, based on brief descriptions of these concepts which were read to them. Details of

their responses are provided in Exhibit 64.

While exploratory in nature, the findings from these two focus groups suggest that while

employers have articulated the pressures they face and the skills and competencies they find

lacking in the workforce, the workers themselves face significant pressures. Not only do

workers face increased workloads, but they also face some unmet needs such as an increase

in pay for more work. Worker’s criticism of increased work without commensurate pay and

staffing approaches such as reengineering will need to be considered if employers aim to

Other job features workers consider to be important

• being appreciated or recognized

• getting incentive pay for good ideas

• having child care at a reduced rate

• having administration listen to input before implementing ideas

• having enough time to do the job

• having management be better and more understanding

• having monthly training sessions

• working with competent people who have a good work ethic

• being able to communicate with management

• having a sense of job security

• having parking available to employees

• restructuring so personnel are used effectively

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E X H I B I T 64: Participant Responses to Workplace Concepts

CAREER MOBILITY AND CAREER LADDERS

Career mobility and ladders are appealing to focus group members, with most saying that these concepts are a good idea. However, many dono feel that they are encouraged to be upwardly mobile, and only a few say that they have access to formal career ladders in their current jobs.Specific reactions included:

• “Career mobility sounds lateral, while ladders imply upward movement”

• “Career mobility is good, because it means you can go to other facilities”

• “There are no ladders for most areas in the hospital—only in nursing”

• “Ladders are a good thing, would be good to have”

• “If you go up the ladder, you might give up some flexibility, or have to do more administrative work”

MULTISKILLINGReactions to the concept of multiskilling or crosstraining were somewhat negative, with many feeling that new skills and responsibilities are beingforced on employees who do not get additional pay for these new duties. Additionally, some are concerned that the training for such newresponsibilities is inadequate. Specific comments were as follows:

• “Multiskilling means we’re going to make you do this, because no one else will do it”

• “We are already doing things other departments used to do, but we’re not being paid for it; if you’re going to

be asked to be flexible, you should get paid more for it”

• “I got training to work in another area, but the hospital decided to get volunteers to do this work, in an effort

to save money”

• “The training you get is not enough to enable you to do a good job in a new area”

• “ Multiskilling benefits the hospital, not the employee”

• “If you get trained in an area that you don’t really like, you won’t do a good job”

REENGINEERINGRespondents view this concept with a great deal of skepticism. No one reported having had a good experience with reengigneering at his or herwork site. Instead, most feel that reengineering is done with a goal of reducing costs, but at the expense of employees and good patient care.Specific comments were:

• “It was done at our hospital, and patients found it confusing, didn’t know who was doing what”

• “The goal of reengineering at our hospital was to cut staff, but it hasn’t happened yet”

• “Now we have aides treating patients, which is against the law”

• “It sounds like down-scaling; people will lose their jobs”

• “This is not good for patient care”

FLEXIBLE WORK SCHEDULESIn general, resppondents view this concept positively, believing that flexibility is good for people with different career goals and family situations.In the two groups, respondents already work a variety of schedules and shifts at the current time. Specific comments included:

• “Flexiblity to work an alternative schedule is good”• “Management tells you what shift and day to work, which is not healthy”• “In our nursing department, we have all three kinds of flexibility”• “Some units have both 12-hour and 8-hour shifts”

sustain and improve their current workforce. The comments from these workers imply that

attention needs to be paid to the worker’s ideas and perceptions in order for the changes in

health care and workforce strategies to be successful.

The preceding four sections of the report presented the demographics and dynamics of

California’s health care delivery system and its allied and auxiliary health care workforce.

Yet, any efforts to improve the workforce’s effectiveness in providing care within an evolving

environment must also include an analysis of the educational system.

Therefore, the next three sections of the report provide an overview of the educational

system in California. Analogous to the broad societal trends that affect the care delivery

system, particular social, political, technological and economic trends influence and shape

California’s educational system. Section VI describes five broad trends and how they are

manifested in the K-12 and higher education systems. Next, Section VII profiles K-12 and

higher education in general, presenting student demographics, financing structures, and

challenges such as class size reduction for K-12 education and the growth of proprietary

education at the postsecondary level.

Finally, Section VIII describes specific health care educational pathways, ranging from K-

12 preparation, vocational training programs for auxiliary occupations and allied health

programs at the postsecondary level. It also outlines how many pathways and programs at the

K-16 level represent educational reform efforts to prepare students to proceed further to

postsecondary education or vocational training, or directly into the workforce. Although

these reform efforts are underway, significant educational shortcomings remain.

Developments such as community-based and on-the-job training are attempting to address

some of these shortcomings and are described in Section VIII as well.


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Important societal trends are shaping California’s educational system. Some of these trends

also affect the health care delivery system and have been described in earlier sections of this

report. Listed below, these trends will continue to alter California’s educational system at

the K-12 and postsecondary levels, affecting the preparation of students for further

education or employment. They are:

• CHANGING STUDENT POPULATIONS

• ADVANCES IN INFORMATION TECHNOLOGY

• MOVEMENT TO A KNOWLEDGE-BASED, SERVICE ECONOMY

• SHIFT IN PUBLIC FINANCIAL SUPPORT FOR EDUCATION

• NEW EMPLOYABILITY SKILLS

A. C H A N G I N G S T U D E N T P O P U L A T I O N S

Students in California’s educational system at the K-12 and postsecondary levels reflect both the

diversity and changing economic composition of the state. These changes are described below.

1. K-12 STUDENT POPULATION

As California’s general population has diversified, so have the students attending public

schools. During the 1995-96 school year, the racial/ethnic make-up of California’s public

school student population was 40.4 percent White, 38.7 percent Hispanic, 8.8 percent

Black, 11.2 percent Asian/Pacific Islander and 0.9 percent American Indian/ Eskimo/Aleut.143

There is diversity in the languages spoken by K-12 students as well. Among the non-English

languages spoken, Spanish, Hmong, Cantonese, Cambodian and Filipino are the most

prevalent.144 In addition, California’s pubic school system must now cope with the fact that

a significant portion of its students live at or near the poverty level. In fact, almost two

million California school children are on public assistance.145 Among children 5 to 11 years

old, 42.5 percent depend on public assistance, while 22.5 percent of children ages 12 to 18

receive public assistance.146

S OC I A L , POL I T I C A L ,T EC H NOLOG I C A L andE C O NOM I C T R E N D SA F F EC T I NG E D UC AT I ON

S E C T I O N VI

2. STUDENTS IN POSTSECONDARY EDUCATION

The demographic profile of students in higher education has changed as well. When California’s

Master Plan for Education was drafted in 1960, a majority of the state’s students were young

(between 18 and 24), male, White and devoted to their studies full-time. Today, the students

enrolled in California’s postsecondary institutions are far more diverse in terms of their full or

part-time status, race/ethnicity and gender, as demonstrated in Exhibit 65.

3. IMPLICATIONS

There are many implications of the changing student demographics for education.

One specific way the racial/ethnic diversity shapes the K-12 education system is that one

in three of California’s public school students speaks a first language other than

English. Of the state’s 5.7 million students enrolled in public schools, approximately

25 percent fall under the Limited English Proficiency (LEP) jj designation.147

Because California also has had a dramatic increase in the K-12 student population

in recent years, the need to educate students in both English and academic content is

especially challenging.

At the postsecondary level, the changing student demographic may necessitate new

efforts for recruitment and student support to successfully matriculate through school.


142


jj. LEP is a term used to define students for whom there is a report of primary language other than Englishon the state-approved Home Language Survey. In addition, LEP students have been determined, on thebasis of the state-approved oral language assessment procedures, to lack the clearly defined English skillsof listening comprehension, speaking, reading and writing necessary to succeed in the school’s regularinstructional programs.

ENROLLMENT GENDER RACE/ETHNICITYSTATUS

Undergraduate Students Full-Time Part-Time Men Women Asian/ Black Latino American White Other UnknownPacific IndianIslander

California Community Colleges 27.7% 72.3% 43.1% 56.9% 9.7% 7.6% 25.6% 1.1% 41.7% 8.4% 5.9%

California State University 75.8% 24.2% 44.6% 55.4% 14.3% 7.9% 23.8% 1.0% 35.0% 10.9% 7.1%

University of California 93.3% 6.7% 47.1% 52.9% 31.69% 3.86% 12.72% 0.78% 39.46% 7.32% 4.16%

Independent Institutions 83.4% 16.6% 44.6% 55.4% 15.8% 4.7% 12.4% 0.9% 57.7% 4.4% 4.3%

Source: California Postsecondary Education Commission, Student Profiles, 1998.

E X H I B I T 65: Characteristics of California Higher Education Students, Fall 1997

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In health careers education, for example, there are higher than average attrition

rates among Black, Hispanic and American Indian/Eskimo/Aleut student groups.

The Health Careers Education 2000 program guide developed by the California

Department of Education therefore recommends educators use models of successful

practices and support materials to expand recruitment to a wider range of students

and reduce attrition rates.148

B. ADVANCES IN INFORMATION TECHNOLOGY

Institutions of higher education have helped create the “electronic revolution” and, in turn,

are strongly affected by it. Low-cost access to the Internet allows colleges and universities to

offer instruction and services in non-traditional formats. In addition, 98.5 percent of the

nation’s public schools have computers. Information technology can alter how and to whom

education is delivered, with the potential to customize learning to the needs and

circumstances of each individual.

Of particular importance is the liberation of the restrictions of time and place that have

characterized education in the past. Some universities have begun to offer courses and some

degree programs online. Although the number of colleges operating via the Internet is

unknown, there is increasing development and use of online programs, despite the

considerable expense of $50,000 to create and support each class.149 One example is the

California Virtual University, a consortium of nearly 100 California universities and

colleges that offers more than 1,600 online courses.

Furthermore, most authorities believe that the electronic revolution will profoundly

change the way higher education is organized and funded. For example, state policy focuses

primarily on the providers of education and financing is based “overwhelmingly on inputs

or activity levels (e.g., student credit hours taught) rather than on outcomes (e.g., student

credit hours completed or educational objectives attained).”150

One university that has shifted to this focus is the innovative Western Governor’s

University, which uses technology in evaluation as a main feature. The University does not

offer courses itself but advertises programs for collegiate institutions and then assesses the

skill levels where students begin and end the program. Using testing centers dispersed

throughout the western states, which are tied together with electronic technology, the WGU

assesses outcomes in numerous skill “domains” such as communications, quantitative

reasoning, critical thinking and problem solving. While this approach to technology and

assessment is still in its infancy, the trend toward greater reliance on outcomes is clear and

strong. Writing as staff to a consortium of states that helped sponsor the electronically

driven Western Governors University, DeWayne Mathews believes that “states will find it

increasingly in their interest to support the mastery of competencies and not just the

accumulation of contact hours.”151

The new educational territory created by the Internet comes with serious issues of validity,

academic freedom, ownership and pay. Using technology in these ways alters the nature of

contact between faculty and student. Concerns also exist that a technological gap is widening

for lower income students. Of households that have an annual income of $75,000 or more,

68 percent own computers. In contrast, of households with annual incomes of $20,000 or

less, only 19 percent own computers.152 This disparity may contribute to an academic

disadvantage for some students by the time they reach college.

The nation is just at the beginning of the revolution of applying technology to the teaching

and learning needs of students. Although there are significant concerns, it provides new

advantages in cost, access and quality.153 As the use of the technology grows and develops

further, it will have a profound effect on how the next generation of allied and auxiliary

health workers learn skills and advance their knowledge throughout a career.

C . M O V E M E N T T O A K N O W L E D G E - B A S E D , S E R V I C E E C O N O M Y

In conjunction with shifting population demographics and advancing information

technology, the United States is evolving into a knowledge-based, service economy.

This economy is increasingly competitive, service-oriented, and held accountable to the

consumer who is more highly informed and educated than in the past. These characteristics

of the economy overall are described in relation to the education sector.

1. AN INCREASING EMPHASIS ON MARKETS, CONSUMER ACCOUNTABILITY AND

COMPETITION IN EDUCATION

For many years after World War II, both federal and state policy strongly

emphasized access to higher education. The strategy for achieving the policy was

essentially through state institutional support and student financial aid from the

federal government. For example, large-scale government programs were established


144


145



to encourage enrollment in certain programs, such as capitation grants for medical

schools and the National Defense Education Act. Other programs such as affirmative

action were designed to encourage certain individuals to attend college and promote

equal educational opportunity.

Today, much skepticism exists regarding these older strategies. Few now believe that large

government programs where institutional grants make education available at low cost to all

students best serve the public.154 Instead, the prevailing attitude is to let markets operate

extensively and thereby determine which institutions the students will attend and what they

receive there. The strategy is to let the public’s knowledge and purchasing power play the

dominant roles in the operating environment for institutions, both public and private.kk

This emphasis on markets has several important effects.

First, many policy makers are now advocating student financial aid as the major

means for government to support higher education, rather than providing access

primarily through large appropriations to public institutions. Another effect is that

institutions must be more accountable to the consumer, giving greater importance

to defining educational outcomes and providing better “consumer information” to

the public. And finally, these markets support competition. One way they generate

competition is to deregulate many aspects of public higher education and encourage

a wider range of institutions and educational experiments. Another way is that

public institutions are encouraged to complete vigorously for private support in

ways unimaginable twenty years ago.

2. THE INCREASING ECONOMIC VALUE OF A COLLEGE DEGREE

Just as educational institutions compete on the basis of outcomes and funding,

students and the future workforce find themselves in a competitive environment.

In this context, there is increasing value to greater knowledge and higher levels of

educational attainment. It is well known that average incomes of individuals rise as

kk. It is important to note that at the same time this societal shift is occurring, there has been an increasein tuition fees, affecting the student’s purchasing power in the education market. This increase can beattributed to the difference between the amount of state funds received and total annual spending byeducational institutions (presented in Section VIIB Exhibit 69), a difference which is, in part, made upby student fees. This increase in tuition is also significant in relation to the shift in public financialsupport, another societal trend affecting education, discussed in the next section.

their educational levels increase. In 1997, adults with a bachelor’s degree earned an

average of 76 percent more than those with only a high school diploma, an increase

from 1975 when the “education gap” was 57 percent.155 What is less well known is

that obtaining some degree, as compared to simply attending college, makes a very

significant difference in income.

Exhibit 66 indicates that a young adult male who holds a college degree makes

almost $11,000 more annually than a man who holds only a high school diploma.

The differential between an individual who has attended some college but not obtained

a degree is significantly less. The failure to complete some college degree, therefore

has serious and negative income consequences for individuals. Over a lifetime,

these differences become even greater.

The shift to a knowledge-based, competitive economy upholds the increasing value

that a college degree and some kinds of certificates have. This shift is occurring as

industrial jobs, which formed the foundation of prosperity during the sixties and

seventies, dwindle rapidly. The RAND Corporation predicts that these jobs will provide

employment for only 10 percent of the workforce by the year 2000.156 Moreover, the

“service-related jobs that are taking their place,” RAND insists, “require a level of

knowledge and skill that, for the most part, can be gained only through programs

offered at colleges and universities.”

RAND predicts that unless educational levels are increased, the real hourly wages of

the average male worker will decline by about 25 percent compared to what the average


146


E X H I B I T 66: Median Annual Income of Males Ages 25-34, 1994

LESS THAN HIGH SCHOOL SOME COLLEGE BACHELORS DEGREE HIGH SCHOOL DIPLOMA OR HIGHER

Annual Income $14,277 $21,180 $24,214 $32,116

Income Ratio* 1.00 1.48 1.69 2.25

Percent Difference** N/A +48.4% +14.3% +32.6%

*Relative to “Less than High School” Income.

**The change between each category.

Source: U.S. Bureau of the Census, 1995 Current Population Survey.

147



male earned in the 1970s. “At the heart of this problem,” the report concludes, “is the

profound change that has taken place in the level of knowledge and skill required to be

a productive worker in today’s economy.”157

Therefore, the message is not just about national economics and earning higher incomes;

it contains a distinct lesson for each individual. In polls, the public’s overwhelming

recognition about the importance of higher education undoubtedly comes from this

message.158 While not all high school graduates want or need a bachelor’s degree, some

postsecondary education or training is increasingly necessary for anyone who wants to

function successfully in the American economy.159 This message serves to both increase

demand for postsecondary education and expand the number of educational providers,

degrees, programs and credentials.

D. S H I F T I N P U B L I C F I N A N C I A L S U P P O R T F O R E D U C A T I O N

Compounding the effects that a changing student population, advancing technology, and

shifting economy have on education is the significant shift in financial support for

education. Specifically, declining appropriations for higher education has noteworthy

implications. This section describes the effects on the educational institutions and their

ability to deliver quality education, as well as the implications for student consumers.

1. FAILING FINANCIAL SUPPORT FROM STATE GOVERNMENTS FOR HIGHER EDUCATION

Despite recent funding increases around the country, higher education receives a smaller

portion of total appropriations among the states than it did two decades ago. Spending on

other government sectors — health, welfare, corrections and K-12 — has grown faster than

in higher education and will likely continue to do so. “Even if the national economy and

state finances return to normal growth patterns without a downturn,” writes Hal Hovey, a

national authority on state finance, “higher education will find itself in an environment

where merely maintaining current services through appropriations reflecting inflation and

enrollment increases will be difficult.”160

Simply to maintain current levels of funding for higher education, the total state

income for colleges and universities would have to rise about 4 percent per full-time

student each year. Hovey projects that this would require state officials to increase their

support by more than the average increase in tax revenues per year — by approximately

0.5 percent each year for the next decade. A few states would not require tax

increases to do this, while others would need to raise taxes about 1 percent a year.161

In a competitive environment for state funds and strong public resistance to tax

increases, it is hard to believe that colleges and universities will be able to maintain

their purchasing power.

2. CHANGING POLICIES FOR TUITION AND STUDENT FINANCIAL AID IN HIGHER EDUCATION

Perhaps the most significant change in higher education finance is in how students pay

for their education. Thirty years ago, the educational costs borne by students (tuition,

fees, and room and board) were paid primarily from savings, family contributions and

wages from summer employment. Today, a much smaller share of student costs comes

from these sources, with a much larger contribution from loans, government need-

based grants, and resources from the colleges themselves.

Student loans have been by far the fastest growing source of support to meet costs.

Nationally, the growth in loan volume far surpassed grants and family contributions

during the 1990s. In fact, loans have become the primary way that many undergraduate

and graduate students finance their education. In California, “college debt more than

doubled between 1990 and 1995, and borrowing has become pervasive,” said Lawrence

Gladieux, author of the decade’s most comprehensive study of California student aid.

“Students 20 to 25 years ago were not expected to borrow money to attend a California

public college or university.”162 A large loan burden can directly influence a student’s

choice of careers, inclining many to avoid public service jobs or geographic areas with

lower paying employment.

Among private institutions, average tuition increases have substantially exceeded

annual inflation rates over the past twenty years. Such increases have both caused, and

been caused by, the practice of “tuition discounting,” or reducing the amount of tuition

actually charged to students who show financial need. Among small colleges around the

nation, such discounting increased from 27 percent of the “posted price of tuition” in

1990 to 38 percent in 1996.163 Among all institutions, discounting increased faster than

the pace of tuition and fee increases between 1986 and 1996.164 This is a vicious cycle for

institutions: an ever-larger portion of “institutional revenues” is being eaten away by

internally generated student financial aid rather than having tuition actually support


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149



instructional expenditures. Donald Kennedy, former president of Stanford, laments

this cycle and the maze of “students deciding where to go-and then trying to figure out,

with their parents, how to pay for it-now encounter a bewildering array of ‘enrollment

strategies’ and offers of discounted tuition.”165

Fortunately, recent developments are serving to reduce these stresses of increasing

tuition, growing student indebtedness, and the loss of institutional revenues to

discounting. In particular, student financial aid has undergone a period of

unprecedented change. After years of eroding support for students attending

independent institutions, the California State government has recently increased the

Cal Grant program substantially. Many states are providing “pre-paid tuition”

programs or tax-free savings accounts to encourage family saving for college

(California adopted this “scholarshare” approach in 1997).166

Also in 1997, the federal government adopted major policy changes. For the first time,

the federal government provided large tax credits for the tuition paid by students and

parents, and re-instituted the ability to deduct interest paid on student loans. These

federal benefits, estimated in the billions of dollars, are targeted at the middle class167 while

pending increases in the federal Pell Grant programs should help lower income students.

E. N E W E M P L O YA B I L I T Y S K I L L S

Given the dramatic growth of technology and other changes occurring in the labor market,

today’s workplace requires skills and competencies that are quite different from those

needed in the past.168 Whether the focus is on students entering the workplace directly from

high school or from postsecondary institutions, employers argue that graduates lack not

only technical skills, but more importantly, the personal attributes necessary to enter and

remain positive members of the workforce.

Recognizing the importance of improving the basic employability skills of high school

graduates, in 1991 the Secretary’s Commission on Achieving Necessary Skills (SCANS) at

the U.S. Department of Labor identified the types of skills that high school students need

to ensure that they could enter and succeed in today’s competitive labor market. SCANS

recognized that the workplace requires workers who have solid foundation skills in basic

literacy and computational skills, including reading, writing, arithmetic, mathematics,

speaking and listening. In addition, students must have the thinking skills necessary to put

knowledge to work, including the ability to learn, to reason, to think creatively, to make

decisions and to solve problems. Finally, employers look for the personal qualities that make

workers dedicated and trustworthy, which SCANS outlines as individual responsibility, self-

esteem and self-management, sociability and integrity.

High-performance workplaces also require the ability to manage resources, to work

amicably and productively in diverse work environments, to acquire and use

information, to master complex systems and to work with a variety of technologies.

Yet, this combination of skills and workplace competencies — “workplace know-how” —

is not taught in many schools nor required for most diplomas.169 SCANS recommends

that all schools incorporate the skills and competencies outlined here into explicit

objectives of instruction.ll 170 To date, SCANS principles have only been implemented in

some school systems.

In addition to the skills acknowledged by SCANS, employers argue that the applicant

pool — graduates from both high school and higher education — lacks both the knowledge

and the personal attributes necessary for work in the current labor market. According

to employment experts, “everyone will have to be able to do something that adds value

now-or be able to learn such value-adding skills quickly...in all but the most marginal

twenty-first century jobs.”171 To succeed, workers must be flexible and solve practical

problems when there are no clear standards for guidance. Robert Sternberg, whose

book Successful Intelligence effectively describes the kind of flexibility needed in the

workplace, argues that the U.S. needs workers who are “intelligent” in three different

ways: analytically, creatively, and practically.

Analytical intelligence is the hallmark of academia: it is the capacity to use existing

knowledge in a structured fashion and evaluate the quality of ideas from pre-existing

principles; its prime value is logic. Creative intelligence is the ability to solve problems

when situations are unclear, the rules are vague, or the principles are non-existent; its

prime value is innovation. Practical intelligence is the ability to solve problems in tandem

with others by accepting circumstances as they are and concentrating on specific goals; its

prime value is effectiveness. Sternberg believes that education prepares students poorly


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ll. In addition, SCANS states that employers must cooperate by incorporating the SCANS “know how” intohuman resource development efforts. Also, the U.S. Department of Labor is looking to build SCANSinto various aspects of Job Training Partnership Act Programs.

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through this almost exclusive attention to analytical skills that will be much less important

later in life than in school. He insists that the emphasis on analytical intelligence is not

wrong, just imbalanced.172

In addition, employers are seeking persons who can work effectively in the constantly

transforming work environment. This environment requires a worker who is not only

competent but also flexible, creative, cooperative and has a strong work ethic. The experience

of William Chance, an educational consultant in Washington, confirms that successful

workers require positive work habits and attitudes, adaptivity, a sound technical and

scientific grounding, entrepreneurship, the ability to read complete material, write well and

communicate, understand problems in mathematical and scientific terms, develop

imaginative and creative abilities and work in teams.

The challenge of implementing SCANS recommendations and imparting creative

intelligence and a strong work ethic in education is compounded by the fact that

the current preparation level of students is not adequate. While high school age

students tend to believe that upon graduation they are prepared to enter the labor

force, employers have less faith in their preparedness. For example, as described in

Exhibit 67, while 57 percent of high school seniors believe that they have the oral

communication skills necessary to enter work, only 9 percent of employers agreed.

Students’ and employers’ perceptions of work preparedness were similarly divided

across most skill areas, with the exception of computer skills in which fewer students

felt “well prepared.”

E X H I B I T 67: High School Seniors’ vs. Employers’ Perceptions about Being Very Well Prepared for Work

SKILL AREA STUDENTS EMPLOYERS

Work in diverse groups 66% 13%

Oral communication 57% 9%

Written communication 45% 6%

Able to meet deadlines 62% 8%

Basic math skills 62% 8%

Basic computer skills 28% 14%

Source: USA Today, June 26, 1997. Roper Starch Worldwide Survey.

At the higher education level, there is a similar disparity between the preparation level of

graduates and the skills employers require. There continues to be a clear mismatch between

even the best, traditional college education and the needs of employers. Students

graduating from higher educational institutions are not developing the skills needed for

success in today’s labor market. “Both academics and employers complain that college

graduation requirements, based primarily on passing sets of courses,” write authors in a

recent survey entitled What Business Wants from Higher Education, “fail to ensure that the graduate

has the personal qualities and skills needed to succeed...These skills include initiative,

persistence, integrity, the ability to communicate effectively, to think creatively as well as

critically, and to work with others to solve problems.”173

The need for a better fit between college education and workplace realities was also

highlighted in a survey of small to medium sized companies that were members of the

National Federation of Independent Businesses. Asked which skills they look for when hiring,

owners cited work habits and occupational skills far ahead of strictly reading and mathematics

skills. Forty percent ranked “occupational skills” as the first choice and 14 percent ranked

these skills as second. The trait that most directly rivaled occupational skills was “work habits”

which was ranked Most Important by 29 percent and second by 36 percent. “To summarize,”

wrote economics professor John Bishop, “in almost all jobs, productivity derives directly

from social abilities (such as good work habits and people skills) that are generic and cognitive

skills specific to the job, occupation, or industry — not from reading, writing, and

mathematics skills. Reading and math skills contribute to productivity by helping the

individual learn the occupation and job-specific skills that are directly productive.”174

Employers also need higher education to provide students with global and multi-

cultural perspectives — knowledge essential in an increasingly diverse workforce and a

competitive world economy. According to the American Council on Education, the nation’s

leading higher education organization, undergraduates need more extensive exposure to

other peoples and perspectives. The Council urges that students receive a “powerful,

deep-rooted understanding of foreign languages, diverse cultures, and global issues.”175

To accomplish this, cultural competence and international perspectives must become

central to the educational enterprise, not just something extra added to the curriculum.

While the level of preparation and the skills and competencies discussed above are of

concern today, they will be even more important in the next century. The necessary


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employability skills already have implications for educational systems, teacher and faculty

development, students and employers. According to SCANS, in order to ensure that K-

12 students are prepared for work in the twenty-first century, dramatic change is needed

within the educational system. First, the issues of inadequate preparation at all education

levels will need to be addressed. To do this in conjunction with implementing the SCANS

foundation and workplace competencies, the U.S. will have to reinvent education,

implement work-based learning and restructure educational assessment. A few of the

health-related educational pathways, structures and programs described in Section VIII

are attempting to create these changes, however much more change is needed.

Additionally, these changes and new demands on education will also have a significant

impact on teacher training and faculty development programs.176


154

While the previous section outlined the issues and trends that have and will continue to

change education in California, this section provides a detailed description of the education

system at the K-12 and postsecondary levels. It first provides a demographic description of

California’s K-12 and higher education system and then outlines the prospective challenges

that both systems face. Issues of student performance and remediation, financing, teacher

supply, appropriate teacher and faculty preparation, proprietary education and the challenges

of accreditation are described. While this section provides a broad overview of education in

general, some issues directly related to health care are also highlighted.

A. K - 1 2 E D U C A T I O N A L S Y S T E M I N C A L I F O R N I A

Given the changing student population, current education funding levels and the skills

required for employment in the new economy, California’s system of public K-12 education

faces a number of significant challenges. The following section provides an overview of public

K-12 education, presenting statistics on enrollment, graduation, attrition and dropout rates.

Additionally, the adequacy of math and science preparation related to health professions

education at the postsecondary level is discussed as well as more general challenges such as the

impact of class size reduction in California and its impact on teacher supply and demand.

1. DEMOGRAPHICS

Enrollment and Projections

In the 1997-98 school year, California’s 8,179 public schools provided education to

approximately 5.7 million of the nation’s 52 million K-12 students. Each year,

approximately 140,000 additional students — the equivalent of 200 new elementary schools

— enter California’s public school system. The California Department of Education

estimates that by the 2000-2001 school year, enrollment will exceed six million

students.177 For the next decade, California is expected to lead the surge in enrollment with

an increase of 30.1 percent. Refer to Section VIA for the description of the diversity of

California’s student population.


P R O F I L E of C A L I FO R N I A ’ SE D UC AT I O NA L S Y S T E M

S E C T I O N VII

Graduation, Attrition and Dropout Rates

Each year since 1980, approximately 200,000 students graduate from California’s public

schools. Recently, both the number and diversity of graduating students have increased. In the

1996-97 academic year, a total of 269,072 students graduated, of which 46.3 percent were

White, 30.5 percent were Hispanic, 14.7 percent were Asian/Pacific Islander, 7.7 percent were

Black and 0.9 percent were American Indian/Eskimo/Aleut. Among these graduates, 36.0

percent met the University of California/California State University entrance requirements.178

While these numbers are increasing, a significant proportion of students do not reach

graduation for a number of reasons. For example, California’s 1996-97 attrition rate,

defined as the number of students who move away, take the general education diploma

(GED), dropout informally or die, was 33.8 percent. Also, the 1996-97 dropout rate of was

3.3 percent, which includes those students who formally sign out of the school system under

the “dropout” designation.179

Low Educational Expenditures for K-12

Despite an education budget of more than $30 billion, California faces financial challenges

primarily because of the tremendous growth in student population, the high cost of living

and the increased service requirements. In 1996, California’s per pupil expenditure was

$5,327, well below the U.S. average of $6,335. This placed the State 41st in comparison to

other states’ expenditures per pupil.180 In terms of public school expenditure related to

personal income, California also ranks well below average. In the 1994-95 school year,

California spent $33 for K-12 schools for every $1,000 in 1995 personal income.

The national average was $40, ranging from $73 in Alaska to $31 in Nevada. By this

measure, California ranked 48th in its school finance effort.181 This financial outlook will

challenge the K-12 education system’s efforts to provide quality education to an increasingly

larger student population with diverse needs.

2. COMPLEX CHALLENGES FOR K-12 REFORM

The state’s system of public education faces a number of complex challenges in educating

students for employment and postsecondary education. Poor performance of California

students in math and science, one of many obstacles facing educators, is specifically

highlighted in the following paragraphs because it is an integral component of preparation for

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156 health care careers. Related to poor performance in math and science, as well as other subjects,

is the issue of class size and the adequacy of teacher preparation and supply. The state’s strategy

to address these problems is also outlined below.

Inadequacy of Math and Science Preparation

At a fundamental level, health professions education is challenged by the lack of adequate

math and science preparation at the primary and secondary levels. California students in

most secondary grades lag behind the nation in mathematics, science and other basic

subjects.182 The poor performance by California students on math and science tests presents

a significant challenge in preparing students for health care careers. The following

paragraphs examine the performance of Californians in math and science and discuss the

implications of this lack of preparation.

The results of the 1996 National Assessment of Educational Progress (NAEP) nationwide

math test, demonstrated that California students perform well below the national average

and are unable to master essential math skills and concepts. California’s fourth graders

trailed their peers in 40 states, only performing ahead of Mississippi, while the state’s eighth

graders lagged behind 32 other states. The test found that 54 percent of the state’s fourth

graders, compared to the nation’s 36 percent, are not mastering essential basic skills such as

measuring an object that is longer than a ruler. Among the state’s eighth graders, 49

percent, compared to the nation’s 38 percent, cannot solve a problem involving money or

fractions. The report also found that only 1 in 10 of the state’s fourth graders, and only 1 in

6 of the eighth graders, are considered “proficient” in math, a skill level higher than merely

mastering the basics. Nationally, 1 in 5 fourth graders met the higher criteria of proficiency

while 1 in 4 eighth graders attained that skill level.183

The statewide Stanford 9 exam,mm administered in 1998, revealed that California school

children also scored below national averages in other basic skills. The nationwide average is, by

definition, the 50th percentile. In math, fourth-graders at the 39th percentile and the state’s

ninth-graders scored in the 50th percentile. In science, the state’s high school students scored

around the 40th percentile.184 Officials claim that the gap in scores between national and state


mm. The Stanford 9 tested students from grades two to eight in reading, mathematics, written expressionand spelling. Students in grades 9 to 11 were tested in reading, mathematics, written expression,science and social sciences.

averages results from the significant number of Californians who are not fluent in English

but who are required to take the exams in English anyway. Approximately 1.4 million of

California’s students in kindergarten through 12th grade have limited English skills.185

To place California’s performance in perspective, it is also important to note that

internationally, U.S. high school students rank near the bottom when it comes to

mathematics and science performance on tests.186 In a comprehensive international exam of

21 nations, U.S. senior high school students were among the industrial world’s least

prepared in mathematics and science. In general mathematics knowledge, U.S. twelfth

graders ranked 19th, outperforming only Cyprus and South Africa, nations which are less

industrialized and have fewer resources than the U.S. In general science knowledge, U.S.

high school seniors ranked 16th.187 Particularly bleak was the performance of the best

American students in advanced subjects such as physics and advanced mathematics, in which

U.S. performance was dead last.188

Most officials cite the shortage of qualified math and science teachers as one source of

these problems. Indeed, some 28 percent of high school math teachers and 18 percent of

science teachers did not major or minor in the subject they now teach.189 Furthermore, in

U.S. public schools, only 10 percent of high school graduates have taken a calculus class and

25 percent have taken physics.190 Such a lapse in education calls for a more intensive math

and science curriculum to prepare future math and science teachers.

Implications - California’s poor performance in preparing students with adequate math

and science skills presents a direct challenge for students enrolling in postsecondary

education as well as those entering the new knowledge-based labor market. While some

require advanced training, many allied and auxiliary occupations require proficiency in

basic math and science skills. In order to ensure that there will be a qualified workforce,

it is crucial that students receive the necessary academic skills.

Class Size Reduction and Teacher Supply and Demand

Related to the challenge of student performance is the issue of class size. Policy makers in

1996 implemented California’s Class Size Reduction Program by providing money to

school districts to reduce the student/teacher ratio to 20 to 1 in Kindergarten through

3rd grade. The reasons, benefits and possible implications of class size reduction are

discussed in the following paragraphs.

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158 In 1996, California’s student to teacher ratio of 22.9 to 1, represented almost six more

students per teacher than the U.S. average. Additionally, the average elementary class size in

1995-96 was 28.8 students, one of the highest in the nation. The high student per teacher

ratio in California has been cited as one of the many reasons for poor student performance

and encouraged policy makers to implement the class size reduction program.

Combined with other important learning and demographic issues, California educators

viewed class size reduction (CSR) as the means to address many of California’s educational

challenges. With the link between smaller class sizes with better academic performance already

confirmed, California implemented a plan to reduce Kindergarten through third grade class

sizes to a goal of 20 students per class, allocating more than four billion dollars since 1996

towards class size reductions. In December 1998, a San Francisco Chronicle article reported on

the California Department of Education’s preliminary findings regarding the impact of class size

reduction on test scores. Based on last spring’s Stanford 9 achievement test, 41 percent of public

school second graders in classes limited to 20 students scored above the national average, while

35 percent of students in larger classes scored above the national average. The results were

similar for third graders. With these preliminary figures, state officials emphasized the need for

more statistical work to determine whether smaller classes do improve academic achievement.191

Implications - Although class size reduction has been praised for improving academic

achievement in Kindergarten through third grade, it has also produces many challenges

and concerns for the education system. CSR has created a critical and immediate

shortage of credentialed teachers in California. It has also focused attention on long-

term issues the State must address if it is to provide qualified teachers for its public

schools. An even greater long-term demand for teachers could come as the result of

retirement and attrition, especially if the intent is to continue to reduce class size for

glade levels four through six. If current trends continue, the supply of teachers will fall

short of increasing demand and add to California’s difficulties in preparing its students

for the workforce.

The implementation of the class size reduction program was, on average, more

expensive than initially projected. The cost of converting classrooms or acquiring new

ones, which was part of the reform effort, was not completely funded. Without adequate

funding, efforts may not be implemented completely and may challenge the success of

this educational reform effort.192


B. P O S T S E C O N D A R Y E D U C A T I O N A L S Y S T E M I N C A L I F O R N I A

California’s system of postsecondary education plays a very important role in preparing

people for employment. As described in the following demographic section,

postsecondary education provides an array of services and serves a very diverse student

population. Following the demographic description, remedial education, teacher

development, segmentation of postsecondary education, proprietary education and

issues surrounding accreditation are also described as significant factors related to the

training of health care professionals.

1. DEMOGRAPHICS

Definition of Postsecondary Education

Postsecondary education is defined as any organized instruction beyond high school.

In addition to colleges and universities, postsecondary education includes vocational

training in schools which issue certificates, adult basic education offered by school districts,

continuing education for professionals, lifelong learning in vocational areas, and

community education sponsored by non-academic organizations and agencies.

The term postsecondary refers to education without reference to level of offering or

student qualifications; it may be for credit or no-credit; it may be a curriculum leading

to a collegiate degree, to a certificate of accomplishment, or to short-term classes for

which no certification of any kind is granted. The corporate sector is among the most

rapidly growing sources of postsecondary education — the 1,000 universities, which

operate within large companies, offer numerous programs and degrees for their

employees and sometimes for others.193

Defined as such, postsecondary education is an enormous enterprise in America,

accounting annually for more than three percent of the nation’s gross domestic product.

Higher education is a part of the postsecondary enterprise and is defined as instruction in

degree-granting colleges and universities which are not solely trade or vocational schools. 194

Typically, these institutions have “regional accreditation,” i.e., they are approved by one of

the nation’s eight, multi-state accrediting associations which evaluate the entire institution.

Regional accreditation is distinct from “program accreditation” which evaluates specific

courses of study, such as the activities of the Accreditation Council for Occupational

Therapy Education or the Commission on Dental Accreditation.

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160

Student Enrollment

Including the “for-profit” schools, almost 2.3 million people are enrolled in California institutions.

(See Exhibit 68) Within the number attending regionally accredited institutions, almost 90 percent

are undergraduate students and are concentrated in the Community Colleges.195

Number, Type, Size and Variety of Postsecondary Institutions in California

The sheer size of the postsecondary enterprise in California is impressive. One hundred and

thirty-nine campuses of public higher education are scattered throughout the State, with a

combined credit enrollment of almost 1.7 million students. Private, accredited institutions

enroll almost 250,000 students, while “ for-profit” schools — most of which term technical

and career programs — enroll another 400,000. The postsecondary enterprise directly

touches 15 percent of all California adults through enrollment or employment.

California’s institutions provide individuals with a vast array of educational choices, ranging

from English courses for recent immigrants to the most advanced medical education in the

world; from cosmetology to comparative literature; from general education to advanced study in

specialized scientific fields; from baccalaureate degrees to certification in nursing.

Postsecondary institutions provide far more than just instruction. They conduct research,

sell products, run hospitals and clinics, maintain residence halls, promote athletic events,

manage radio and television stations, perform public service of all kinds, and accept gifts

and donations. Exhibit 69 indicates that California postsecondary institutions in 1997 spent

more than $27 billion in providing these activities. It is interesting to note that all of these


E X H I B I T 68: Credit Enrollment in California Postsecondary Institutions, Fall 1997

POSTSECONDARY INSTITUTIONS HEADCOUNT ENROLLMENT PERCENT OF TOTAL ENROLLMENT*

California Community Colleges 1,142,912 50.1%

California State University 343,779 15.1%

University of California 169,862 7.4%

Independent Institutions 219,827 9.6%

Proprietary (for-profit) Institutions** 400,000 17.5%

Out of State Institutions** 4,816 0.2%

TOTAL ENROLLMENT 2,281,196 100%

*Accredited and non-accredited institutions**Latest enrollment data is 1995.Source: California Postsecondary Education Commission, Student Profiles, 1998.

higher education institutions have a budget that is much larger than the state funds that they

are allocated. For example, the University of California system in 1997 had an annual

budget of $11.1 billion and yet they only received $2.3 billion in state funds. A large portion

of the difference is received through student enrollment fees and many of the other activities

mentioned above. A description of the financial support system for the postsecondary system

in California is discussed in Section VID.

The higher education sector consists of public colleges and universities and regionally

accredited, “independent” institutions, which are described in turn. The 1960 California

Master Plan for Higher Education organized public institutions into separate systems or,

more accurately, into tiers of campuses with distinctive missions and different governance

structures. These tiers of campuses were called segments.

• The most exclusive segment is the University of California with its nine campuses,

including one devoted exclusively to health sciences.196 The UC enrolls only the most

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E X H I B I T 69: The Campuses and Economic Size of Postsecondary Education in California, 1997

HIGHER EDUCATION SEGMENT/SECTOR CAMPUSES/ ANNUAL STATE TOTAL ANNUAL LOCATIONS GENERAL FUNDS SPENDING (BILLIONS)

(BILLIONS***)

California Community Colleges 106 $3.2 $3.6

California State University* 22 $1.9 $3.8

University of California* 9 $2.3 $11.1

Independent Institutions** 72 $0.2 $6.5

TOTAL-REGIONALLY ACCREDITED 209 $7.6 $25.0

OTHER POSTSECONDARYINSTITUTIONS**

State Approved Private & Vocational Schools 2,100 sites $0.01 $1.30

K-12 Adult Schools 250 districts $0.45 $0.48

Regional Occupational Programs 30 counties $0.27 $0.29

TOTAL OTHER NA $0.74 $2.07

*UC and CSU Extension enroll hundreds of thousands of students with no state funding.**Members of the Association of Independent California Colleges and Universities only.***Includes state-funded student financial aid provided through the Student Aid Commission.Source: California Citizens Commission on Higher Education, p.15.


162 academically able undergraduate students, including transfers from community

colleges. The University’s mission is heavily directed toward research and graduate

education, and it is the only public institution responsible for advanced education for

health professionals and for five medical schools and hospitals.

• The largest four-year segment is the California State University with twenty-two

campuses. The CSU emphasizes undergraduate academic education with graduate-level

work restricted to the master’s level, primarily in the fields of business, social work,

education, engineering and the health sciences. The CSU is more accommodating of

part-time students than is the University of California and enrolls large numbers of

Community College transfer students (60 percent of CSU baccalaureate holders have

credits from California’s two-year colleges).197

• The third segment consists of the California Community Colleges, whose 107 campuses

are, by law, open door institutions which must admit any California resident over 18 years

of age. These colleges offer freshmen and sophomore-level courses whose credit can be

transferred to universities, general education/community college credit courses, non-

credit education, and vocational programs such as those in the health professions,

electronic equipment assembly, software production, graphic design and manufacturing.

California has an impressive sector of accredited institutions which consists of private,

non-profit colleges and universities which range from small specialty colleges in the arts

to world famous research universities. Although these independent institutions enroll

only twelve percent of all higher education students in California, they grant one quarter

of all baccalaureates in California and one-half of all the state’s advanced graduate and

professional degrees. Independent institutions make a substantial contribution to the

education of health care professionals. In 1995, these institutions alone conferred more

than 1,200 degrees in the fields of dentistry, medicine, optometry, chiropractic

medicine and pharmacy.198

Proprietary Education

The growth of proprietary schools is reshaping the postsecondary educational landscape.

In recent years, there has been a dramatic increase in the number of students registering in

degree programs at non-traditional, for-profit educational institutions. In fact, Appolo


Group Campuses, which includes the University of Phoenix, the Institute of Professional

Development, and Western International University, has experienced a 55 percent increase

in its enrollment nationally between 1992 to 1996.199

In 1994-95, approximately 776 proprietary schools (all non-collegiate institutions) offered

postsecondary education in California.200 Of the 776 schools, 116 are accredited by the

Accrediting Commission of Career Schools and Colleges of Technology (ACCSCT). Some of

these schools offer programs in allied health education, for example, of the 116 schools accredited

by ACCSCT in California, 50 offered programs in allied and auxiliary health careers.201 These

programs offered both certificate and degree programs, including: Medical Billing; Phlebotomy;

Medical and Dental Assisting; Certified Nursing Assisting and Home Health Aide training.

2. ISSUES FOR POSTSECONDARY EDUCATION

California’s system of K-12 education is not alone in facing a number of highly complex

challenges. Remedial education, faculty and teacher development, segmentation among the

number of distinct systems of higher education, the growth of proprietary education and

accreditation issues challenge the state’s system of higher education. While some of these

challenges are distinct to postsecondary education, others such as remedial education are a

direct result of performance at the K-12 level. These five issues are outlined, highlighting

the implications for the production of health professionals.

Remedial Education

A significant number of students in California’s colleges and universities enroll in remedial

education courses. Within the California State University (CSU) system, the percentage

of CSU freshmen failing their proficiency exam was at an all-time high in mathematics

(54 percent) and English (47 percent) in 1997. Data also show that in 1997 the California

State University system had the highest number of freshmen in the 22-campus system requiring

remedial education courses in subjects that they should have learned in high school.202

Nationally, while the percentage of high school students who go directly from high school

to college continues to rise, a high percentage of freshmen also enroll in remedial education

courses. In the fall of 1995, 29 percent of first-time freshmen enrolled in at least one

remedial course, with freshmen being more likely to enroll in remedial mathematics courses

than in remedial reading or writing courses.203, 204 Additionally, 40 percent of freshmen

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164 requiring remediation are older students re-enrolling in college.205 With these statistics,

it is not surprising that a 1995 survey found that 78 percent of higher education

institutions in the U.S. offer at least one remedial reading, writing or mathematics

course.206 In addition, 100 percent of public two-year institutions nationally offered

remedial courses.207

While there is no evidence that remediation has increased in size or scope nationally,

offering such courses continues to raise several issues for the higher education institutions

that provide them. First, providing remedial education requires institutions to use both

financial and human resources. Recent analysis suggests that remediation costs require

approximately $1 billion annually in the public higher education budget of $115 billion —

less than 1 percent of total expenditures. These estimates parallel California where the cost

of remedial education in the UC and CSU systems represented less than 1 percent of total

expenditures in 1995. In that year, CSU indicated that the annual cost for remedial

education was $9.3 million.208 In California Community Colleges where about 121,000

full-time-equivalent students were enrolled in remedial education courses in fall 1993, the

estimated cost of remedial education in 1993-94 was about $365 million.

Implications - Although remedial education plays a crucial role in the education system,

not all remedial education is delivered effectively or efficiently.209 A 1998 report on

remediation recommends implementing multiple strategies that help to reduce the need

for remediation in higher education as well as improving its effectiveness when it is

offered in higher education.210 In order to reduce the need for remediation, high school

requirements and course content must be aligned with college content and competency

expectations. Early interventions and financial aid programs targeted to students at the

K-12 level that link mentoring, tutoring, and academic guidance with a guarantee of

college financial aid must be implemented or bolstered. Further, high school feedback

systems must be developed along with improving teacher preparation. Finally, the report

recommends improving the effectiveness of remediation in higher education with inter-

institutional collaboration and utilizing technology to enhance and effectively provide

remedial courses.211

These strategies for improving the remediation system rely on one important element —

collaboration. Collaboration at all levels is crucial, including collaborations between, among

and within: colleges, universities and high schools; states and their colleges and universities;


and businesses and all levels of education. A reluctance to develop adequate and efficient

collaborations will thwart efforts to appropriately address the issue of remediation.212

Lack of Appropriate Faculty and Teacher Development

Over the past three decades there has been considerable professionalization of the training

programs associated with allied health. The pathways to many of these careers was once a very

informal process of on-the-job training or learning new technologies from manufacturers

of new diagnostic and therapeutic equipment. As a way of improving the quality of care and

establishing professional identity, many of these informal pathways to allied health work

have moved into the formal training programs of academic institutions. Along the way,

many of these activities have followed a well-established pattern of professionalization.

Typically this has meant limiting entry licensure to those that graduate from an accredited

program, expanding the requirements for accreditation and limiting accreditation to

academic programs and degrees, and lengthening the time of training to match the formal

degree period of associate, baccalaureate and masters level training.213

One of great challenges facing education as it responds to the issues of a new health care

environment and the skills needed by health care workers is how to ensure that faculty and

teachers have an appropriate understanding of this environment and the necessary skills to

prepare their students. As the report documents, the changing health care system challenges

teachers to respond to issues of work readiness, new professional roles, a rapidly changing

health care environment, and new organizational skills and competencies. The Pew Health

Professions Commission has recently identified 21 competencies that will be needed for success

in the next century. Each of these will have an impact on the allied and auxiliary workforce.

Implications - To meet such a challenge the teaching staff and faculty must develop the following:

• An understanding of how the health system is changing

• An ability to relate new information technologies into care delivery settings

• An appreciation of what work readiness expectations will be made of their students

• A capacity to relate the traditional clinical content to the new context of care

• An ability to use new teaching and learning technologies

For the most part, these challenges will require new skills and competencies on the part of

faculty. Much of this can only be learned through a more fundamental effort to embrace and

integrate care delivery and education.

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166 California’s Approach to “Segmentation” and the Effect on Student Transfer

Since 1960, California has organized its public campuses into “segmented” tiers of

campuses where an institutional mission is the single most distinguishing and

permanent feature. The California Master Plan drew clear lines between the research-

oriented University of California and the teaching-oriented California State

University; between Community Colleges with open access and public universities with

restricted admission pools; between public institutions with line-item appropriations

and the private sector where government support was only provided indirectly through

student financial aid; and between the K-12 schools as feeders and higher education as

receivers of students. Through both direction in the Master Plan and strong tradition

in California, each is responsible for its own course-credit standards.

These Master Plan distinctions among the segments were intended to promote order

during the growth of higher education, prevent turf wars, reduce expensive “mission creep”

where campuses expand their scope for more prestige, and provide clear messages to the

public about admissions policies and other campus features.

No doubt, Californians have benefited from the orderly development of higher

education, widespread initial access to higher education, and clarity of institutional

roles and responsibilities — all fostered by segmentation. From the student’s

standpoint, however, there are disadvantages to such a highly segmented approach.

The limitations created by thge segmented approach may explain why California does

not have a good record for completion of undergraduate degrees.

One example of a troublesome disconnect is the transfer function of the California

Community Colleges. Approximately 11,000 students transfer annually to UC,

47,000 to the CSU, and 4,000 to independent institutions — out of a total credit

enrollment of more than 1.1 million.

Many factors, of course, serve to hold down the number of transfer students:

some community colleges do not place a priority on their transfer programs; some

do not have strong relations with four-year institutions; and many students have

insufficient knowledge about which credits will transfer toward the kinds of degrees

or majors they seek. Unlike several states, California does not have a “common

course numbering” system which would assign a single number to most transfer-

credit courses. Nor does California have a central repository for all “articulation”


agreementsnn that link specific community college courses to requirements among all four-

year institutions. The strong segmentation approach has not served to change these factors.

Several developments over the past ten years have reduced this confusion over awarding

credits after transfer, especially the statutory mandate for a uniform “Intersegmental

General Education Transfer Curriculum” and recent improvements in electronic databases

about course articulation. Still, Governor Gray Davis remains concerned about “reports of

students who, after transferring to another institution (often within the same system), are

required to repeat classes already taken.”214

Implications - The barriers to student transfer have special significance for vocationally-oriented

programs, such as those in the health professions. To best serve students in these programs,

which have extensive requirements and quite specific content for courses, the curriculum must

be well integrated among the high schools, the two-year institutions and four-year universities

which offer different levels of education often in the same areas.

This need for extensive articulation among institutions becomes even more important

when a state’s higher education system is highly segmented and where students must know

long in advance of transfer exactly what is required by their final degree program.

Growth of Proprietary Education

The growth of proprietary schools is reshaping the postsecondary educational landscape

and is challenging traditional educational institutions, including schools of allied

health. In recent years, there has been a dramatic increase in the number of students

registering in degree programs at non-traditional, for-profit educational institutions.

For-profit institutions market to working adults and cater their curricula to meet the

needs of their students and local employers. With a customer focus, these universities

typically focus on preparing their students for the current labor force. And, they are

able to change curricula more rapidly than traditional educational institutions in order

to reflect the needs of local employers. This section outlines the reasons for proprietary

167



nn. Articulation refers to the process where academic departments or entire institutions agree that specificcourses are comparable to, or serve as replacements for, other courses. Articulation occurs on many levelssince courses fulfill many different functions: general education requirements, pre-requisites for higher levelcourses, or courses which fulfill requirements for an undergraduate major. Certainly such “articulation”agreements in a state as large and complex as California will always prove thorny, especially since faculty andinstitutions have the prerogative to decide which credits will transfer for which kinds of requirements.


168 education’s success, outlining key characteristics of these institutions and their future

direction in the educational system.

Reasons for Success of Proprietary Education - In response to the increase in the number of

students registered in degree-granting programs of non-traditional universities, the

California State University commissioned a study of proprietary schools in 1997. National

University and the University of Phoenix agreed to participate in the study as subject

institutions and allowed full access to their campuses and faculty. The researchers concluded

that these schools are not educating scholars or academic specialists, but they are training

students for specific careers. Also, when compared to traditional universities, these for-profit

institutions excel in their ability to respond to the constantly changing needs of their clients

who include both students and employers. The for-profit institutions reviewed were more

service oriented and focused on customer satisfaction by providing individual advising and

flexible scheduling and course work.

Reduced Time Investment and Convenient Class Scheduling - Proprietary institutions compete

with traditional, non-profit educational institutions for students by providing the same

training in a shorter amount of time. Programs through non-traditional, for-profit

institutions are typically offered in a one-course per month, one — or two — evenings-per-

week format specifically geared toward the adult learner. Depending on the number of

college credits a student has when entering the university, degree programs can be

completed in as little as 12 to 16 months.215

These proprietary schools provide academic flexibility by employing a small core faculty

and establishing a network of adjunct and part-time lecturers. These part-time employees

are interested in teaching in the evening, which matches the needs of the students who work

full-time. Part-time faculty also provide budgetary and course flexibility and are

compensated typically without fringe benefits. Not only is there academic flexibility, but

there is also academic innovation as these students and faculty focus on practical solutions

and mechanisms that work in the market. This approach to teaching is highly attractive to

both the student consumer and the employer financial sponsor.

Though students benefit from the shortened time frame and the flexible class schedule,

for-profit institutions are typically more expensive than traditional non-profit public

universities. In both public and private traditional universities, financial aid is provided to

assist students. The higher cost of proprietary institutions has not hindered the growth of


proprietary schools. Due to the conditions described above, students are willing to pay the

extra cost in order to shorten the amount of time it takes to earn a degree.

Different Teaching Methods - Another example of innovation is the “active learning”

approach proprietary schools commonly take in education. Under this model, students take

primary responsibility for learning the course material. Students are provided with a

textbook, a course outline and other learning resources, and they are expected to cover the

course material on their own. Instructors guide, mentor and address student issues, and

typically use class time to expand on, instead of review, the course material.216

Implications - For-profit universities are now expanding their curricula and adjusting

their marketing strategies to appeal to a broader segment of the student market. Although

challenges for proprietary schools do exist, they are succeeding. As described above, students,

including students in allied and auxiliary health care fields, are seeking an education that is

flexible, focused on a specific career goal and can be completed in the shortest amount of

time possible. Therefore, unless traditional educational institutions choose to adapt to the

changing needs of the population they serve, proprietary institutions will continue to

expand their market share.217

Barriers Posed by Accreditation

Another significant challenge facing the educational sector is accreditation, the voluntary, non-

governmental process that judges the effectiveness of educational programs against predetermined

standards. While accreditation standards and the process of accreditation have the potential to

provide health professions education with a foundation and a guide to continually improve, the

current state of accreditation indicates that these objectives are not always being met. This section

provides a definition of accreditation, a list of accrediting bodies for several allied health

professions, and an overview of issues regarding accreditation. Much of this work is drawn from a

study conducted by the Task Force on Accreditation of Health Professions Education (Task Force)

convened at the Center for the Health Professions, University of California, San Francisco.

The Task Force concluded the following shortcomings in the current state of accreditation:

• There is a lack of study or proof of the added value accreditation provides.

• There is significant duplication and waste in the accreditation process, such as overlap

between regional and specialized accreditors, the same data reported in different

formats, and accreditation requirements that do not add value.

169




170 • Although competency-based performance assessment is a shared outcome of regulation

and accreditation, there is no linkage currently between these two mechanisms.

• Some accreditation standards are inflexible and out-of-date.

• Accreditation standards and processes have not adapted to an interdisciplinary model

that is used increasingly in professional education and health care delivery.

• There is a need to shift from an oversight, periodic evaluation perspective for the

accreditation process to one of self-assessment and continual improvement.218

Definition - The American Medical Association defines accreditation as a process of

external peer review in which a private, non-government agency or association grants

public recognition to an institution or specialized program of study that meets

established qualifications and educational standards, as determined through periodic

evaluations. In theory, the process encourages educational institutions and programs to

evaluate continuously and improve their processes and outcomes. For institutions,

accreditation is supposed to protect against internal and external pressures to modify

programs for reasons that are not educationally sound. It also should involve faculty and

staff in comprehensive program and institutional evaluation and planning, while

stimulating self-improvement through national standards against which the institution

can evaluate the program it sponsors. Accreditation can also help prospective students

identify institutions with programs that meet standards established by and for the

field(s) in which they are interested, and assist those who wish to transfer from one

institution to another.

List of Accrediting Bodies for Allied Health - A list of accrediting agencies and respective

allied health occupations for which they accredit programs appears in Exhibit 70.

These accrediting bodies represent 35 allied health professions. While existing

requirements for accreditation vary depending on the accrediting body, the core

requirements of all of these agencies include: a) a site visit which distinguishes

accreditation and approval of a program; b) established accreditation standards

and compliance with standards that allow the student consumer to transfer among

programs in their field of specialization and that offer the general public some

assurance that health professionals are uniformly trained; c) professional peer

review, which attempts to integrate continuous improvement principles into the


171



ACCREDITING AGENCY OCCUPATIONS

ACCREDITATION COUNCIL FOR Occupational Therapist

OCCUPATIONAL THERAPY EDUCATION Occupational Therapy Assistant

(ACOTE)

COMMISSION ON ACCREDITATION OF Althletic Trainer

ALLIED HEALTH EDUCATION PROGRAMS Cardiovascular Technologist

(CAAHEP) Cytotechnologist

Diagnostic Medical Sonographer

Electroneurodiagnostic Technologist

Emergency Medical Technician-Paramedic

Health Information Technician

Medical Assistant

Medical Illustrator

Ophthalmic Medical Technician/Technologist

Orthotist/Prosthetist

Perfusionist

Physician Assistant

Respiratory Therapist

Respiratory Therapist Technician

Specialist in Blood Bank Technology

Surgical Technologist

E X H I B I T 70: List of Accrediting Bodies for Allied Health

accreditation process; d) public disclosure of accreditation status; e) lay public

involvement in the accreditation process; and f) recognition of accreditation.

Implications and Recommendations - The extent to which the intended positive outcomes of

accrediting bodies’ activities are realized was the topic of discussion of the Task Force. With

the shortcomings of current accreditation processes (outlined in this section’s

introduction) in mind, the goal of the Task Force was to make recommendations to improve

the accreditation process so that it better meets evolving educational, health care industry

and broader social needs. The Task Force established key principles of accreditation

COMMISSION ON ACCREDITATION/ Dietetic Technician

APPROVAL FOR DIETETICS EDUCATION Dietitan/Nutritionist

(CAADE) OF THE AMERICAN DIETETIC

ASSOCIATION

(continue)


172

including: 1) to assure the public of a quality program; 2) to promote continuing self-

improvement; 3) to establish a minimum threshold of professional preparation of practice;

4) to promote an integrated means of assessment and improvement; and 5) to accomplish

all of the above while minimizing waste and duplication.

The Task Force identified several factors that needed modification in order to

improve accreditation:

• Improved clarity about the purpose of accreditation, particularly regarding

the role of protecting the public and improving the quality of institutional

programs and operations;

• Diversified approaches to accreditation that would expand beyond the current

heavy dependence on written analysis of structures and processes associated with

programs under review;

• Movement away from narrowly cast judgements in time to move interactive approaches

focused on improving quality; and

• Revamping of the convoluted structure of accreditation in order to achieve clarity of purpose,

clear lines of authority, greater flexibility and the use of more evidenced-based approaches.


COMMISSION ON DENTAL Dental Assistant

ACCREDITATION (CDA) OF THE AMERICAN Dental Hygientist

DENTAL ASSOCIATION Dental Laboratory Technician

COUNCIL ON ACADEMIC ACCREDITATION Audiologist

IN AUDIOLOGY AND SPEECH-LANGUAGE Speech-language Pathologist

PATHOLOGY

JOINT COMMITTEE ON EDUCATION Radiation Therapist

IN RADIOLOGIC TRAINING (JRCERT) Radiographer

JOINT REVIEW COMMITTEE ON Nuclear Medicine Technologist

EDUCATION PROGRAMS IN NUCLEAR

MEDICINE TECHNOLOGY (JRCNMT)

NATIONAL ACCREDITING AGENCY FOR Clinical Laboratory Technician/Medical Laboratory

CLINICAL LABORATORY SCIENCES Technician-Associate Degree

(NAACLS) Clinical Laboratory Technician/Medical Laboratory

Technician– Certificate

Clinical Laboratory Scientist/Medical Technologist

Histologic Technician/Technologist

Pathologists’ Assistant

E X H I B I T 70: (continued from page 171)

Alterations in the accreditation process must respond to the needs of the public, reward

innovation and improve efficiency. Given the necessary modifications outlined above, the

Task Force has established the following recommendations:

• Shared Responsibility to the Demands of the Public - To increase public accountability,

the educational process carried out by institutions, programs and accreditors needs

to be directly linked to the changing demands of the public, employers,

professional bodies and students. The accrediting process needs to be

conceptualized by all constituents as an integral part of a larger system of program

review, improvement and regulation. This new conceptualization can be

encouraged by establishing competencies for practice, collecting and monitoring

practice needs, creating threshold levels of program performance and having

ongoing dialogue with all constituents.

• Improvement Model - An assessment approach in education, that relies upon an

improvement model, needs to be created. In this model, accreditation would be a

critical activity of intentional improvement. Undertaking a systems approach,

with the understanding that change is an improvement, will facilitate institutions,

programs, and accreditors to accomplish objectives and collect evidence of

tangible change.

• Efficiency - Efficiency needs to be brought to bear on the accreditation process.

Streamlining and increasing accountability, reducing duplication and waste, and

considering common data collection will greatly enhance the current accreditation

processes. Greater flexibility in accreditation could be realized, along with a

reduction in costs associated with the practice. To do so, the accreditation process

needs to encourage and reward innovative methods and measures that enhance efficiency.

• “5+1” Approach - A consistently applied “5+1” approach to accreditation by all

specialized and professional accrediting agencies is needed. An agreed upon five

criteria with one unique criterion that is profession-specific would allow

accrediting agencies to collect and compile comparable data. The common five

criteria state that an educational program: 1) is connected with the community and

public; 2) provides faculty development and evaluation; 3) assesses the

competencies of students and graduates; 4) has a process of continuous

improvement; and 5) informs and accurately represents itself to its public to

173




174 ensure accountability and consumer choice. The accreditation process could then

be more market-driven and outcome and competency-based.

• Action-oriented Accreditation Process - Sustaining an action-oriented accreditation process

that facilitates necessary and prompt change in educational processes is needed.

This can be accomplished by professionally training accreditors. These individuals

will have the ability to accelerate change, given their pivotal role in the accreditation

process. From this, modified approaches can be developed and audited. This would

then ensure that accrediting agencies are responsive to stakeholder needs and interests.


The following section outlines the strategies and training programs targeted at preparing

students and workers for careers in health care. This discussion provides an understanding

of the efforts that the educational system is undertaking to meet the changing demands of

the workforce and care delivery system. Four broad training areas are addressed:

• An overview of selected K-16 educational programs, pathways and approaches for

preparing students for health care careers and postsecondary education in the

health professions.

• A description and discussion of California’s allied health educational programs at the

postsecondary level based on original survey work.

• An overview of the types and variety of selected training programs for auxiliary occupations.

• A discussion of the growing importance of on-the-job training and the implications of

this movement, particularly for unlicensed assistive personnel.

A. D E S C R I P T I O N O F H E A LT H - S P E C I F I C E D U C A T I O N A L P A T H W AY S

A number of strategies and programs aim to prepare students for careers in health care at

the K-16 level. The variety of programs, pathways and approaches to preparing students

to enter the health care labor force are described below. A number of programs and

initiatives have been created to address some of the changing demands discussed in

Section VI. While the programs and initiatives described below do not represent a complete

list, they provide examples of the types of educational and training opportunities available.

It should be noted that in addition to preparing students for health care, some of the

following programs also provide preparatory training for a variety of other careers.

1. THE SCHOOL-TO-WORK/CAREER PROCESS

In May 1994, the federal School-to-Work Opportunities Act (STWOA) was signed into law

and created a framework for the development of the School-to-Work system. The federal

law requires states to develop a comprehensive educational system that includes the

integration of school-based learning, work-based learning and connecting activities that,

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H E A LT H - S PE C I F I CE D UC AT I O N andT R A I N I NG P R O G R A M S

S E C T I O N VIII


176 for example, match students with employers for mentoring and training opportunities.219

The goal of the federal program is to prepare all students at all levels of the educational

system for an economy that demands that workers have strong basic knowledge and skills, are

adaptable to change and are prepared for life long learning. School-to-Work/Career is a

recent movement in education that has been created to meet the changing demands of both

industry and postsecondary institutions.

In California, this initiative is referred to as School-to-Career (STC) and calls for reforms

in the educational system that include, for all students, the integration of school-based and

work-based learning, the use of contextual, applied teaching strategies, and the opportunity

for students to select career-related coursework and workplace experiences.220 School-to-

Career is not a separate, discrete program but a sustained, structured pattern of study that

integrates school-based and work-based instruction from Kindergarten through high school

and beyond.221 The vision of California’s school reform effort is that “every student has access

to the same rigorous coursework, is prepared to meet high academic standards and is

prepared to enter both postsecondary education and/or the workforce.”222

California received initial funding for School-to-Career in November 1996 and will receive

a projected $131.4 million over a five-year period. Given that School-to Career is a recent effort,

the transition will take a number of years to complete. The State funds local STC partnerships

through competitive grants that: integrate the STC principles throughout the educational

system; connect school-based and work-based learning opportunities; promote community

support for continued STC development after state funding ceases; and link STC efforts across

education segments and with other major initiatives involving education, economic

development, workforce development, Welfare-to-Work and One-Stop Career Centers.223

Given that the goal of the school-to-work movement is to prepare young people to better

participate in a learning-intensive economy and society, outcomes of these programs need

to be determined by observing the performance of individuals, firms and the economy as a

whole over the next few decades. Currently, short-term evaluations have been conducted as

well as personal testimonies that exemplify the individual effects of school-to-work

partnerships. Evaluations of several School-to-Work programs oo also indicate several

positive outcomes for students enrolled in these programs. Such outcomes include


oo. The evaluations of the programs are outlined in School-to-Work, College And Career: Review OfPolicy, Practice, And Results 1993-1997 by the National Center for Research in Vocational Education.

177



decreased absences, increased grade point averages and full-time employment following

graduation. As outlined in the story “School to Career in Practice”, these partnerships can also be

evaluated by the accomplishments of those enrolled in the programs.224

School-to-Career in Practice: Serving All Students

East Bakersfield High School Health Careers Academy, Bakersfield, California.

(Reprinted and edited from the California Department of Education)

Raoul entered high school in Bakersfield as a “high-risk” student. The only member of his

family who spoke English and the first to enter high school, Raoul lived with his grandmother

and a large extended family in a two-room house.

He entered the Academy as a sophomore with poor reading and language skills as well as low

self esteem. Not surprisingly, Raoul’s initial grades were low and remained low until the end

of his first year in the Academy. However, through many of the experiences provided at the

Academy, Raoul discovered that he had the ability to succeed in a health care career.

During a job shadowing experience at Kern Medical Center, students were asked to

help move the emergency room into a new facility. In the process, the staff at Kern

Medical Center discovered that Raoul spoke Spanish and engaged him as an official

translator. In one instance, an elderly Hispanic gentleman, who was terrified of the

hospital, came into the emergency room in enormous pain. Raoul’s first task was to calm

the patient and then translate for the medical staff. When the patient encounter was

finished, one physician put his arm around Raoul’s shoulder and said, “Right now, you

are as important to this hospital as I am.”

Raoul went on to develop expertise in orthopedics through another job shadowing

opportunity. He received evaluations that were glowing, with supervisors using phrases

such as: “eager to learn, reliable, self-directed, and an asset to the department.”

A number of traits that Raoul learned on the job also influenced his classroom work.

Raoul demonstrated a strong work ethic in the classroom and encouraged other students

to pursue their studies. He particularly influenced one friend who never would have

finished the program without Raoul’s support. By the end of his junior year,

(continue)



Raoul developed considerable self esteem in and out of the classroom, and was working

towards specific learning and career goals.

As a result, Raoul is working for the summer at the Kern Medical Center though a JTPA

funded position in Orthopedics. His various responsibilities include directing patients

into examining rooms, ensuring that doctors have materials such as charts and X-rays and

helping in the cast room. He is also training junior auxiliary volunteers in orthopedics.


2. HEALTH CAREERS EDUCATION PROGRAM

The conceptual model of the health careers education program was developed by the

California Department of Education in order to respond to the changing needs of industry

and to respond to various reports which have called for a better-educated and well-prepared

health care workforce. The health careers curriculum spans the education process, beginning

in elementary school and concluding at the educational level chosen by the student.225

While the first Health Careers Education (HCE) course was offered in 1956 and focused on

vocational nursing, health education programs have expanded to include courses in

medical, dental, health care information and nursing professions. These programs are

offered in high schools, adult skill and continuing education centers, and regional

occupational centers/programs (ROC/Ps). The number of health occupations programs at

the high school level has grown steadily. In 1996-97 over 67,500 students enrolled in

health career education programs — a total of 4,030 in secondary schools, 44,621 in

ROC/Ps and 19,294 at adult skill centers.226

The goals of the health careers education program include:227

• Enabling students to make career decisions that are consistent with their aptitudes,

interests, abilities and academic achievement;

• Providing a program of instruction that prepares students for postsecondary education

and for employment;

• Enabling more students to achieve higher levels of academic and career preparation;

• Providing added relevancy and meaning to the students’ educational program of

learning from Kindergarten through career; and

• Eliminating the need for remediation for students in the health careers program who

wish to enter postsecondary education or employment.

Although in the past, health careers education programs were limited to job-specific

training at the twelfth grade and postsecondary education levels, they place special emphasis

on career exploration in the earlier grades. Parallel to the School-to Career concept, HCE

programs encourage early career exploration and decision making. However, it is crucial

that career choice is based not only on the interests of the student but also on the student’s

aptitude, academic achievement and educational goals.228

HCE programs include several components, including career exploration, integration of

health care content into the curriculum, and preparation for specific health care careers

or postsecondary training programs. HCE programs focus on integrating health care

content into the curriculum, beginning with awareness activities, exercises and projects in

the elementary grades, progressing with increased complexity and rigor and career

specificity in the middle grades. Finally, in high school students are introduced and

prepared for specific health care careers.

Specific training programs can vary in length. For example, preparation for an assistant-

level career can be completed as part of the student’s high school program through the local

ROC/P or adult skill center. However, technical-level careers usually require either a

certificate program that can be completed at a ROC/P or an adult skill center or an associate

degree from a community college. Some students also continue on to receive a bachelor’s or

postgraduate degree in health related fields.229

In general, the health careers program focuses on student-centered education that connects

schoolwork to life experiences and produces a graduate prepared for a productive, satisfying

work life. It is important to note that at any decision-making point along the health careers path,

students may determine that health care is not their career choice and may at that point exit to

explore other career areas. The skills and knowledge gained during a health careers education

program are transferable to other careers or disciplines that a student may choose to explore.

3. HEALTH CAREERS EDUCATION PATHWAYS

Health Career Education programs, as explained above, can be provided through secondary

schools, regional occupation centers/programs and adult skill centers. While this does not

provide a comprehensive list of all possible pathways, a description of California Partnership

Academies and the Regional Occupational Center/Program (ROC/P) is provided below.

179




180 California Partnership Academies

A California Partnership Academy model is a high school-based approach that is currently

in place in approximately 250 California high schools. Whether they receive state funding

or not, academies incorporate many of the features of the school-to Work/Career

movement. Some of the features include curriculum focused on a career theme, voluntary

student selection of a career path, team teaching and a variety of motivational activities.

Partnership academies (or career academies) prepare students academically and vocationally

for either entrance to college or careers in a selected field such as agriculture, arts and

entertainment, aviation/transportation, business, computer technology, education,

health/medical and law/government. These programs must include a partnership among a

school district, community colleges, local employers and the California Department of

Education. Of the programs listed in the California Partnership Academy Directory,

23 listed a health/medical emphasis.230

The typical partnership academy is a three-year progression with students entering during

their sophomore year of high school. The program consists of block scheduling to allow

students greater flexibility for a variety of additional activities such as field trips. Students are

required, unless summer school is necessary for graduation, to complete an internship in the

summer following their junior year and those students who are performing well are given jobs

in a local business. Academy teachers must commit to teamwork in curricula development and

integrating vocational areas into their academic lessons. Finally, academy programs must have

a steering committee or advisory council consisting of individuals from the local school

district, school administrators, teachers, and representatives from the business sector to guide

the program. The committee reviews policies and procedures as well as makes recommendations

to ensure that the partnership is meeting both the students’ educational and career goals.231

Regional Occupational Centers and Programs

Regional Occupational Centers and Programs (ROC/Ps) offer both high school and adult

students entry-level career or technical training skills. As outlined in Exhibit 71, ROC/Ps

offer vocational education and training for a variety of careers, including health careers.

In California, as of 1995, there was a total of 73 ROC/Ps offering training in 47 health

career areas.232 During the 1996-97 school year, 44,621 students were enrolled in health

careers programs at regional occupational centers/programs. (See Exhibit 71)


California Regional Occupational Centers and Programs provide secondary students and

adults an opportunity to attend a cost-effective career education, entry-level career or a

technical training program. ROC/Ps play a crucial role in the health careers education

program. Students enrolled in an HCE program can receive health career-specific

education and training at local ROC/Ps in areas such as dental assisting, medical assisting,

medical records clerk, home health aide and restorative aide.

These are two examples of many pathways that a student may choose in order to complete

their education in a health careers program. These programs provide students with an

opportunity to extensively explore a specific career path and prepare for both entry into the

workforce and postsecondary education.

4. HEALTH OCCUPATIONS STUDENTS OF AMERICA (HOSA)

Health Occupations Students of America (HOSA) is an integral part of the health

careers program. HOSA is a vocational student organization comprised of secondary

and postsecondary/collegiate students. Through interactions with professional, business

and other student organizations, HOSA members strengthen their leadership and

citizenship abilities in addition to developing the skills necessary to acquiring a job in

the health care industry. Since its inception in 1976, HOSA has grown steadily.

In the 1993-94 membership year, HOSA had nearly 60,000 student members in

thirty-seven states with 1,900 chapters. In 1999, California HOSA maintains a

membership of 1,400 students.233

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E X H I B I T 71: Regional Occupational Centers and Regional Occupational Programs, Secondary (High School) and Adult Enrollment by Program, 1996–97

TYPE OF ENROLLMENT *SECONDARY ADULT TOTAL

Agriculture 13,534 2,604 16,138

Business Office & Marketing 109,800 87,020 196,820

Health Careers 15,691 28,930 44,621

Consumer Homemaking & Home Economics 28,042 7,216 35,258

Industrial & Technology 94,721 68,384 163,105

State Total 261,788 194,154 455,942

*Calculataed estimates based on concurrent/non-concurrent rates applied to annual enrollment totals by program.Source: VE-80B, ROC/P Annual Enrollment Report, FY 1996-1997, Report 3, “Report of ROC/P Course Enrollment Totals By Ethnicity, FY 1996-1997” and “Report ofROC/P Course Enrollment Status Totals, FY 1996-1997.”


182 HOSA’s mission is both to promote career opportunities in the health care industry

and to enhance the delivery of quality health care to all people by providing opportunities

for knowledge, skills and leadership development of all health occupations students.

When students enroll in any health careers education program, the student has the opportunity

to become a member of their local HOSA chapter.

The HOSA experience influences health career students by providing them with a variety

of opportunities through local, regional, state and national activities. These activities

include educational workshops, leadership training, business sessions, election of state

officers and mentoring opportunities. As the HOSA student progresses through their

experience, they gain leadership skills such as decision-making, team building,

professionalism and work ethic. They have the opportunity to participate in competitive

events, run for state or local office and serve on a variety of committees. Students who

participate in HOSA find, after graduation, that they are better prepared for success in a

postsecondary education program or entering the world of work.234

B. D E S C R I P T I O N O F A L L I E D H E A LT H P R O G R A M S AT T H E P O S T S E C O N D A R Y L E V E L

Following graduation from the K-12 system, a student seeking a career in allied health can

do so via various programs. However, these programs face a number of challenges and

demands from the care delivery system. The following discussion includes an overview of

allied health training programs and demographics of the students enrolled in these

programs as well as an explanation of some of the responses by education to meet care

delivery’s changing requirements.

1. CURRENT ALLIED HEALTH PROGRAMS

Overview - Currently, no single source collects and compiles comprehensive program and

student profile information regarding all allied health education and training programs in

California. The American Medical Association’s (AMA) Health Professions Education

Directory provides information on allied health education programs and the California

Postsecondary Education Commission’s (CPEC) Student Profiles 1998, provides a description

of the degrees awarded in the health professions among public, four-year institutions.

According to CPEC, during the past decade, enrollment and graduation patterns

have fluctuated within the category of “health professions and related sciences.”235


Throughout higher education, the number of baccalaureate degrees has increased substantially

between 1987 and 1996, although the number awarded at the University of California fell

by almost half. In terms of percent increase, masters degrees have been the most rapidly

growing in the UC and the CSU systems. Exhibit 72 shows the degrees awarded in the health

professions for selected years, followed by several measures of change in those years.

In addition, the American Medical Association’s (AMA) Health Professions Education

Directory provides a comprehensive listing of nearly 5,000 allied health educational

programs enrolling approximately 150,000 students in 2,094 sponsoring institutions

throughout the country. It also provides aggregate enrollment, graduate and attrition data for

3,559 programs, nationally and by state, and is updated annually.

For California, the 1997-98 Health Professions Education Directory identifies 151 unique

allied health institutions providing training in 302 allied health programs. These institutions

are dispersed throughout the state, and include four-year colleges and universities,

institutions within the community college system, and private for-profit vocational and

technical institutions. During the 1995-96 academic year, there were 12,072 students and

5,658 graduates of these allied health programs.

2. SURVEY OF PROGRAMS

To expand on the AMA directory, the Project developed a survey of California’s allied

health programs with questions regarding program length, degrees awarded, structure,

institutional profit status and class size. The survey also gathered current information on the

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E X H I B I T 72: Degrees Awarded in “Health Professions and Related Sciences” among California Four-Year Institutions, Selected Years Between 1987-88 and 1996-97

PERCENT PERCENT OF PERCENT OFCHANGE TOTAL TOTAL

DEGREES DEGREES

Segment/Sector 1987-88 1990-91 1993-94 1996-97 1987-1996 1987-88 1996-97

University of California

Baccalaureate Degrees 340 320 275 180 -47.1% 1.4% 0.6%

Master‘s Degrees 687 803 782 680 -1.0% 11.7% 10.9%

Doctoral Degrees 85 117 117 129 51.8% 3.7% 4.6%

First Professional Degrees 1,092 1,090 1,131 1,175 7.6% 59.2% 60.2%

California State University

Baccalaureate Degrees 1,968 1,853 2,600 2,913 48.0% 4.2% 5.6%

Master’s Degrees 577 646 1,161 1,067 84.9% 6.4% 9.0%

Source: California Postsecondary Education Commission, Student Profiles 1998.


184 racial/ethnic composition of students in allied health programs, as the AMA ceased the

collection of this information in 1995. In addition, the survey obtained updates on new and

terminated allied health programs since the completion of the AMA report.

A survey was designed and sent to all 151 deans or program directors of these allied health

institutions in California. Responses were received from 82 of these institutions, a 54.3

percent response rate. The total number of responses varied for each individual question

since all 82 respondents did not answer all questions. While not a large enough sample to

allow for quantitative analysis, the following findings emerged from this survey.

Results - Based on responses to the survey, the majority (38.6 percent) of allied health

programs are offered within various educational settings where there are one to two allied health

educational programs available. Seven institutions (8.4 percent) were each found to sponsor

more than 11 allied health programs, accounting for nearly one-third of all of the programs in

California. Sixteen institutions (19.3 percent) offered 6 to 10 allied health certificate or degree

programs, and 26 institutions (31.3 percent) offered between 3 to 5 programs. These programs

are distributed predominantly in the following counties: Los Angeles (31.6 percent);

San Bernardino (11.6 percent); San Francisco (8.6 percent); San Diego (8.3 percent);

Sacramento (6.0 percent); Orange County (5.6 percent); and San Mateo (2.0 percent).

3. STUDENT DEMOGRAPHICS

While only 38 programs, representing 6,325 allied health students, responded to the

question on ethnic composition of students, the data provide an estimate of the

racial/ethnic composition of current allied health students to compare to that of the

California population. According to the 1996 Population Projections by the U.S. Bureau

of the Census, the racial/ethnic breakdown of the California population was 51.7 percent

White, 6.7 percent Black, 30.2 percent Hispanic, 10.8 percent Asian/Pacific Islander and

0.6 percent American Indian/Eskimo/Aleut. (See Exhibit 73) The racial/ethnic composition

of allied health students in California parallels that of the state population, except for

differences among Hispanic students and Asian/Pacific Islander students. Hispanic

students are consistently underrepresented while Asian/Pacific Islander students are

consistently overrepresented in relation to the general population. Exhibit 73 compares the

racial/ethnic composition of all the allied health students as well as three sub groups of

students to the composition of the California population.


Within allied health education, however, differences exist in the racial/ethnic distribution

of students among certain levels of programs depending on the type of degree attained.

Among the advanced educational programs, there is a disparity between the Black, Hispanic,

Asian/Pacific Islander and American Indian/Eskimo/Aleut allied health student population

sand the general California population. Conversely, the student demographics of the basic

educational programs are fairly similar to the demographics of the State population.

For the advanced level of educational programs, masters level physical therapy programs

responding to this question were examined separately from the certificate, associate

and bachelor level allied health students. Next, dietetics, respiratory therapy and

radiographer programs that responded to this question were examined as examples of

allied health programs that require a moderate level of academic preparation (associates and

bachelors degrees). These programs that represent four years of training or less are

comprised of a higher percentage of minority students. Finally, allied health students in

medical assistant programs, as examples of certificate and diploma programs, reflect the

highest concentration of non-white students in the field, as shown in Exhibit 73.

4. CHANGES IN PROGRAMS

In addition to collecting data on the racial/ethnic composition of current allied health

students, the Project’s survey also collected information regarding changes in education

programs throughout California. The addition or closure of programs reflect the priorities

of and challenges faced by allied health educational institutions. These implications of

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E X H I B I T 73: Comparison of California Allied Health Student Demographics: 1996 Population Estimates versus All, Advanced, Moderate and Basic Level Programs Responding to Race/Ethnicity Survey Question

WHITE BLACK HISPANIC ASIAN/PACIFIC AMERICAN OTHERISLANDER INDIAN/ESKIMO/

ALEUT

California Population 51.7% 6.7% 30.2% 10.8% 0.6%

All Allied Health 48.8% 8.7% 22.8% 12.2% 1.9% 5.5%Students (n=6,325)

Advanced Allied HealthPrograms (n=869 68.1% 1.4% 4.0% 22.1% 0.7% 3.7%students)

Moderate Allied HealthPrograms (n=1,227 59.2% 3.3% 12.5% 19.7% 1.3% 4.0%students)

Basic Allied HealthPrograms (n=3,886 41.3% 11.8% 30.8% 6.7% 2.7% 6.8%students)

Source: U.S.Bureau of the Census–Population Division. U.S. Population Estimates by Age, Sex, Race and Hispanic Origin: 1980 to 1997.


186 program changes are indicated. Also, the priorities of allied health program leaders are

described in Allied Health Program Deans and Directors on Priorities for the Future.

Program Additions - Overall, 12 new allied health programs were reported among the

respondents. From respondents who listed the type of new program, a demand for allied health

workers at the certificate or associates level is seen. The institutions that responded indicated a

number of shifts, many reflecting adjustments to cost pressures and changing employment

opportunities. The following lists some of the new programs:

• Dental Hygienist

• Physical Therapy Assistant

• Speech and Language Pathology via Distance Learning

• Certified Nurse Assistant

• Home Health Aide

• Medical Unit Specialist - Billing/Coding Specialist

• Respiratory Therapist

Furthermore, from informal interviews, the Project discovered that the College of Allied

Health at Loma Linda University initiated a masters level program for Health Information

Managers in the fall of 1998, to prepare graduates for information system design and

management in health care settings. The strategic plan for Allied Health at Loma Linda also

calls for the development of distance learning capacities in numerous areas, extending the

educational effort into underserved communities. Additionally, the College of Allied

Health at Charles Drew University introduced a Nurse Midwifery Program at the masters

level in response to cost pressures regarding maternity care under managed care, as well as a

Coding Specialist program targeted for welfare beneficiaries seeking career opportunities.

Program Closures - Respondents also identified 15 terminated programs. Several of

the terminated programs within the allied health institutions responding to the survey

are listed below:

• Respiratory Therapist

• Clinical Lab Scientist/Medical Lab Technician

• Ophthalmic Technician

• Diagnostic Coding Technician

• Medical Office Lab Assistant


• Dental Assistant

• Radiology Technician

• Medical Technician

• Cytotechnologist

The terminated programs reflect a decline in certificate programs. Explanations for program

terminations alluded to the need to respond to excess costs associated with low enrollment

and the pressures associated with limited entry-level positions upon graduation. Among the

responses to changes in programs, there were no programs providing allied health

professionals with knowledge and skill in designing and interfacing with telemedicine

systems, or administering managed care systems. Moreover, only one program intended to

pursue developing distance learning capacities.

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Allied Health Program Deans and Directors on Priorities for the Future

A follow-up survey was sent to deans and directors of the 151 allied health programs in

California to identify the priorities of the allied health educational leadership. Forty-three

responses from 39 of the institutions were received. This summary of the responses serves

as an indication of how allied health education is positioning itself for the twenty-first century.

A list of twenty-three issues including curriculum development, availability of clinical

teaching sites, preparedness of faculty and advancing technology was compiled.

Respondents were asked to rate each issue in terms of importance on a 5-point Likert

scale, with “1” equal to “Very high priority” and “5” equal to “Very low priority”.

The five issues receiving high priority ratings most frequently were:

• Securing adequate numbers and types of clinical training sites

• Monitoring the shifting health care market

• Responding to students as consumers

• Responding to health care providers as consumers

• Improving in-service training and competence in faculty

While respondents indicated these issues as high priorities, it appears that achieving these

goals requires further work and change by the educational system.


188 C. D E S C R I P T I O N O F A U X I L I A R Y T R A I N I N G P R O G R A M S

Auxiliary training programs vary widely in terms of skill standards, location, funding and

administration. Much of the training for these occupations is learned on the job and while

some auxiliary occupations require certification by a statewide exam, others require

documentation of on-the-job training. Furthermore, training programs are offered at a

range of venues: high school/regional occupation programs, vocational programs, adult

school, community college or a health care facility. Funding and administration of these

programs can either be private or federally supported.

In recognition of the variety of training programs and lack of standardization among

them, the Project here profiles an illustrative sample of training programs, specifically:

home health aide, nurse aide and certified nursing assistant (CNA) training programs.

Given the significant amount of on-the-job training and the variety of tasks that these

personnel may perform, information regarding typical duties, wage rates, entrance

requirements and other workplace issues are also profiled for home health aides, nurse aides

and CNAs. Additionally, examples of the different ways in which such auxiliary training

programs are funded and administered are presented, such as Job Training Partnership Act

(JTPA) and community-based programs.

1. PROFILE, NUMBER AND DISTRIBUTION OF PROGRAMS

Home Health Aide

Definition - Home health aides (HHAs) provide assistance to patients who cannot live

independently. They assist the patient with personal care and home care activities so the

patient can stay at home rather than move to a nursing home. Employed by private hospitals

and clinics and non-profit community health agencies, HHAs work under the supervision

of a registered nurse or physical therapist in carrying out the physician’s treatment plan.

Skills and Duties - The Occupational Research Unit of the Employment Development

Department’s (EDD) Labor Market Information Division (LMID) lists the minimum skill

requirements for HHAs at job entry. Some particularly necessary skills include an ability to

prepare meals and apply patient transferring techniques, oral communication skills, and an

ability to work independently and perform CPR.

Once employed, the typical duties of HHAs include helping the patient perform bodily

functions, checking pulse and breathing rates, changing bandages, and ensuring that the


patient follows his or her daily medical regimen. In addition, HHAs are responsible for

planning and implementing personalized meals, coordinating patient care with other

members of the health care team, and keeping records of patient care. Because the aides deal

with incapacitated patients, they must also be able to handle patient suffering that might be

due to physical or emotional problems at home.

Entrance Requirements and Training - In California, the State Department of Health Services

(DHS) issues a HHA certificate to those who have completed a minimum of 65 hours of

supervised clinical training and 55 hours of classroom training in an approved home health

training program. No federal competency examination is required for certification.

Generally, agencies do not require a high school diploma when hiring HHAs.

Certified nursing assistants can become HHAs by taking an approved 40-hour

supplemental certification program, which focuses on home health care functions and duties.

Additionally, programs exist which provide dual certification training to become a CNA and

HHA. Although opportunities for promotion are rare, HHAs can acquire additional training

to become Medical Assistants, Licensed Vocational Nurses or Registered Nurses.236

As of August 1998, California has 563 HHA approved training programs, though the

number of programs fluctuates daily. Based on the DHS’ list of approximately 300 HHA

training programs in California, the following is the estimated distribution of programs at

the following settings: High School/Regional Occupational Program (R.O.P.) — 24 percent,

Vocational Education — 36 percent, Adult School — 16 percent, Community College —

20 percent and Hospital — 4 percent.

Viewing the distribution by region, Los Angeles has the greatest number of HHA training

programs, approximately one third of the State’s total. Outside of Los Angeles County, the

majority of training programs are in Southern California, particularly in Orange County,

Riverside, San Bernardino and San Diego. In Central and Northern California, at least

nine programs exist in each county of Fresno, Alameda, Sacramento, San Francisco and

Santa Clara. In contrast, most rural counties, such as Colusa, Humboldt, Sutter, Yolo,

Tuolomne and Modoc, have only one training program for HHAs.

Employment Growth and Wages - According to the California Employment Projections

report, the HHA is the sixth fastest growing occupation in the State. In 1996, there were

495,000 HHAs, but the number is estimated to reach 873,000 by the year 2006,

climbing 76 percent. This tremendous projection of growth is greatly due to the nation’s

189




190 aging population that continues to grow and live longer, and most will ultimately require

some form of medical help in the form of HHAs or other support positions.

Despite high demand for HHAs, wage rates range from minimum wage to $14 per hour

for full-time or part-time work, depending on the needs of the agency. Many agencies hire

only “on call” hourly workers with no benefits while others hire aides on a set full-time or

part-time basis with regular benefits.237

Workplace Issues - HHAs are important members of the home-care team, usually led by

registered nurses and physicians. However, aides sometimes report feeling ignored by the

nurses with whom they share patient care. In a 1994 Gilbert study on the interaction between

the HHA and the supervising nurse, HHAs indicated they did not receive enough guidance

from their supervisors; this, in turn, contributed to their dissatisfaction with the job.

In addition to the aide-nurse relationship issue, HHAs also face other issues that generate

problems in recruitment and retention, such as inadequate wages, poor benefits, instability of

work hours, inadequate support and supervision, and lack of professional advancement.238

Nurse Aide

Definition - Nurse aides work under the close supervision of nursing and medical staff in

clinics, public health agencies and acute care hospitals. Their job requires less skill and

training than that of a CNA who earns a certificate of training and passing a federal

competency test. (See Certified Nursing Assistant profile)

Skills and Duties - Some necessary job entry skills for nurse aides include an understanding

of asepsis, an ability to apply patient transferring techniques, an ability to read and follow

directions, a willingness to work with close supervision and an ability to handle crisis situations.

Once on the job, the duties of nurse aides range from highly involved patient contact to

cleaning tasks. Patient care duties include taking vital signs, measuring food and liquid intake

and output, assisting with personal hygiene, helping with exercises, and preparing for

examinations or surgery. Non-clinical duties include cleaning treatment trays and other

supplies, processing patient documents, and scheduling appointments. Nurse aides can also

work in patients’ homes, where they provide nonprofessional nursing care and help with

personal hygiene. Based on the responses from the hospital surveys, some larger hospitals

reported crosstraining nurse aides in additional skills, including EKG, phlebotomy,

monitoring technician skills and ward clerk skills. From these respondents, the survey found


that the most needed skills and competencies indicated for nurse aides were acute care

skills, good communication skills, computer skills, a strong work ethic and ability to give

feedback to nurses.

Entrance Requirements and Training - Nurse aides are required to have a high school diploma,

but they do not have to be certified by the State. Most employers are willing to provide on-

the-job training to those who lack prior experience in the field. Training lasts one to nine

weeks under the close supervision of a general duty nurse or licensed practical nurse,

depending on the individual’s abilities.239

Although the nurse aide is an entry-level position in the field of nursing, no formal line

of promotion exists. However, with additional training and schooling, aides can work in a

specialty area such as pediatrics, geriatrics, surgery and others. Moreover, an aide can earn

a bachelors degree in nursing to become a Registered Nurse. Employers can encourage

advancement by providing training within the facility and by offering flexible work schedules

to facilitate formal classroom study.240

Employment Growth and Wages - According to the California Employment Projections

report, the number of nurse aides, orderlies, and attendants in 1996 was 1,312,000 and is

estimated to grow 25 percent to 1,645,000 by the year 2006. Nurse aides rank ninth

among the 50 occupations with the largest job growth. Employment is expected to grow

due to the continuing emphasis on rehabilitation and the long-term care needs of an

aging population. Because of the broad range of the education and experience levels of the

employee pool, wage rates range from minimum wage up to $17 an hour for the most highly

experienced aides.241

Workforce Issues - Among the health care team, composed of the allied health workforce

and the licensed professionals, roles often overlap. While all components of the health care

team are committed to fulfilling the needs of the patient, aides may encounter problems

when their roles overlap those responsibilities of other allied health assistants. In addition,

the lack of career ladders and understaffing are also concerns of the workers. In the Project’s

hospital surveys, only 3 out of 19 hospitals reported advancement opportunities for 25 to 50

percent of nurse aides. Both smaller and larger hospitals reported offering advancement

opportunities for less than 25 percent of their nurse aides.

Furthermore, given the current trend to hire more CNAs who can work in both acute care

hospitals as well as in skilled nursing facilities (SNFs), nurse aides who have been working in

191




192 the hospital setting for many years face new competition. Hospitals tend to hire CNAs

who have worked for SNFs to work in the acute care setting as well to preserve liability.

No concrete evidence exists that demonstrates CNAs work better in acute care settings than

nurse aides do, but the hospitals want the added coverage from the certification of the

CNAs. Most of the hospitals from the survey sample reported the use of CNA certification

as an employment criterion for nurse aides.

Interviews also revealed that nurse aides feel increasing pressure from hospitals to work in

SNFs. Hospitals are buying SNFs and moving their patients into those facilities since it is

less expensive than having patients stay in hospital beds. However, SNFs require CNAs

rather than nurse aides. For those nurse aides who have been working in the hospital setting

for numerous years, the new shift is more than an inconvenience. Though they have years

of experience behind them, they are required to earn certification by undergoing many

extra hours of training that they have already acquired through experience on the job.

Certified Nursing Assistant

Definition - CNAs work in hospitals and long-term care facilities to provide support services

on a 24-hour basis for convalescents, the elderly and chronically ill patients.

Skills and Duties - CNAs are qualified to perform all the same duties as nurse aides, but they

come under stricter government regulations because of their certified status. However, there

are some additional skills required, such as administering some medications, increased

patient contact due to their long-term care setting and using on-line medical records.

Entrance Requirements and Training - In California, the Department of Health Services

requires a minimum of 100 hours of supervised clinical training and 50 hours of classroom

training in long-term health care. Unlike the HHAs, CNAs must complete the training as

well as pass the Federal Competency Test to earn certification.

Although the number of training programs changes constantly, the count was 820 as of

August 1998. Based on a list of approximately 300 schools which offer CNA training

programs in California from the DHS, the estimated distribution of programs across the

following settings is: High School/R.O.P. — 34 percent, Vocational Education Organization

— 27 percent, Adult School — 17 percent and Community College — 22 percent.

Looking at distribution of programs by region, almost half of all training programs are

concentrated in the Southern California counties of Los Angeles, San Diego, Orange


County and Riverside. In Central and Northern California, a substantial number of

CNA training schools exist in Fresno, San Mateo and Alameda counties. Interestingly,

San Francisco, a large metropolitan area, has fewer schools than Tulare County does.

Various counties such as Yuba, Humboldt, Mendocino, Tuolumne, Colusa, Siskiyou and

Amador, which are mainly rural counties, have only one school or training facility for CNAs.

Employment Growth and Wages - The employment projections for CNAs are the same as those

for the Nurse Aides since the LMID of the EDD does not distinguish between the two

occupations. Therefore, refer to the nurse aide profile for the values.

Workforce Issues - Many important issues make the CNA role in the long-term care

industry vulnerable. One is the high turnover rate among CNAs, which adversely affects

patient satisfaction, care, worker morale and finances. Based on the 1997 OSHPD data from

long-term care facilities, the overall employee turnover rate for this care delivery setting is

67.8 percent. A high turnover rate has been linked to several factors, including employee

pay and benefits. Workers are apt to change jobs for meager wage increases. Some employers

may come in direct competition with the fast-food industry for the same employee pool,

because it offers the same or higher starting wages for less demanding work. Perhaps the

most difficult problem for management is the workers’ poor self-perception and motivation.

Moreover, in the wake of the investigation of abuse and negligence by California nursing

homes, the role of CNAs may come under increased scrutiny. The New York Times has quoted

a Senate panel in saying, “the administration had done nothing to address the....shortage of

nursing assistants and other personnel at many homes.”242 An editorial in the Los Angeles

Times also addressed the personnel shortage. This piece called for California lawmakers to

change “an outrageous state law that allows nursing homes to greatly inflate representations of

the amount of care provided by registered nurses,” and nursing homes to set “clear, minimum

staffing levels so one nursing assistant isn’t hand-feeding two dozen patients.”243

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194 A Better Way: Royal Oaks CNA Training Program

The CNA retention rate at the Royal Oaks Convalescent Home in Galt, California is most

likely one of the highest in the State. Depending on the year, the facility usually has 40

CNAs and approximately five to six leave each year, equating to a 15 percent turnover rate.

This compares to the 100 percent or higher turnover rates at many California facilities.

Given the rural location of Royal Oaks, recruitment is “pretty tough,” so the facility has

designed an improved CNA training program to ensure a steady supply of CNAs who

actually stay with the facility after graduation.

The small class size and unique structure of the class are factors of the program’s success.

The class runs three times a year, usually with 30 applicants for 6 to 8 class spaces.

Beverly, the corporation that owns Royal Oaks, pays for the hourly wages of the students

while they are in class. In the latest class in October 1998, seven out of eight students

completed the program. One very unique aspect of the program is that it requires the

students to train for 30 clinical hours beyond the standard 100 hours (plus 50 class hours)

the State requires. The additional hours allow the instructor to key in on certain

difficulties the class may be having rather than to teach new skills. Overall, the theory is

that a better-prepared CNA is less likely to leave.

After the students finish the program and start work, they enter orientation. This entails

two days with the Director of Staff Development. Students then pair up with a more senior

CNA for a buddy system approach for three months. The facility provides a healthy

working environment by emphasizing attendance, teamwork that develops into loyalty, and

appreciation of the new CNA’s transition into a professional role. After CNAs have

worked for 90 days, they are eligible for a wage increase. After that, wages increase yearly.

Royal Oaks regularly pays their personnel above minimum wage. The benefits are

generous, with medical and dental coverage (at less than 50 percent of the premium) for

full-time employees who work more than 30 hours a week.

Another advantage to continuing work at Royal Oaks is the opportunity for promotion.

After one year of work at the facility, CNAs are eligible for tuition reimbursement and

unpaid time off for health-related schooling. An estimated 10 to 25 percent of the CNAs

take advantage of the advancement opportunities, which is higher than most places that

(continue)


195




report no advancement. Most CNAs move into rehabilitation positions, though there have

been examples of movement into Certified Occupational Therapy Aide or Assistant

positions, clerical positions, supervisory roles in dietary, housekeeping and clerical positions.

The present Facility Administrator, DSD and dietary supervisor all started out as CNAs, so

the facility’s culture is built on advancement. The facility tries to build a CNA’s self esteem

to advance. Those who take advantage of the free schooling tend to stay with the facility

because they have formed close bonds with the residents and staff.

Overall, the Royal Oaks program presents an interesting training model. It appears

that Royal Oak’s rural location positively impacts the facility, with staff demonstrating

more forward thinking about recruitment and retention. They have created a more

rigorous CNA training program and career pathways for CNA advancement. In addtition,

they offer generous benefits, provide educational assistance and encourage all

employees to advance.

2. JOB TRAINING PARTNERSHIP ACT PROGRAMS

The federal and state government supports and funds various programs that train the

population to make the transition into the workforce. Since much of the auxiliary health care

workforce represents entry-level positions, federal programs target training programs for such

occupations. One example is The Job Training Partnership Act (JTPA), which provides

funding for numerous job-training services throughout the state of California, including

support for allied and auxiliary health training programs. The act, which became effective in

1983, seeks to move jobless individuals into permanent self-sustaining employment.

JTPA programs are available for economically disadvantaged adults and youth, dislocated

workers and those who face significant employment barriers. Eligibility requirements for

funding depend on factors such as economic sufficiency and employment barriers. Aside

from job training, JTPA programs also provide a variety of services, including in-depth

assessment of skills and abilities, classroom training, job search assistance, counseling and

support services. One JTPA program that provides LVN training for current CNAs is profiled

in Emanuel Medical Center’s LVN Training Program.

In terms of governance, the governor of each state is responsible for the implementation

and operation of JTPA. In California, the Family Economic Security Act designated the


196

Emanuel Medical Center’s LVN Training Program: A JTPA Program in Profile

The Licensed Vocational Nursing (LVN) training program at Emanuel Medical Center

boasts a 98 percent placement rate for its graduates. In its latest summer class, the

program prepared approximately 30 CNAs to become LVNs, many of whom had been

welfare recipients. The program trains CNAs to become LVNs with the skills to work in

hospitals, skilled nursing facilities or outpatient clinics. To carry out the program, the

Emanuel Medical Center collaborates with the Private Industry Council of Stanislaus

County and the JTPA Program based at Turlock Adult School.

The hospital essentially pays for everything from tuition to childcare support. Jean

Haskell, Emanuel’s Vice President of Human Resources, says the hospital benefits in many

ways by offering this program. First, the hospital can meet any LVN shortages it may

experience. In addition to placements at Emanuel, the program’s graduates are employed

in other acute care settings, medical offices and long-term care settings as well. Haskell

asserts that the program exemplifies a successful business partnership and that it meets an

important social need for the community.

In partnership, Emanuel directs the program, selecting students referred through the

JTPA program as well as provides classroom space and equipment. In each class,

(continue)


Employment Development Department (EDD) as the state agency to oversee the administration

of the program. The State Job Training Coordinating Council provides policy guidance to the

EDD and also serves as the Governor’s advisory body assisting the governor in planning,

coordinating and monitoring the JTPA programs and services. In California, JTPA funds are

distributed among the 52 Service Delivery Areas (SDAs) that are designated by the governor to

receive federal job training funds. The SDA is responsible for the day-to-day operation of the

JTPA programs in their area. The local Private Industry Council (PIC) — comprised of

representatives from private sector businesses, organized labor, community-based

organizations, local government agencies and local educational agencies — provides policy

guidance and coordinates with the SDA to develop local strategies for providing JTPA training

and services.244 This coordination between the government, the community and private

businesses is essential to successfully implement a JTPA program.

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five to ten of the students come from Emanuel’s own workforce. Students are either current

CNAs or equivalently experienced individuals who enter the 18-month training program.

The LVN students are carefully interviewed and selected by a group consisting of the

program director, Judy Black, two of the program faculty from Emanuel, and a student

officer who is a graduate from one of the previous classes.

JTPA and the Private Industry Council of Stanislaus County

The PIC of Stanislaus County not only provides funds for the LVN program, but it also works

in partnership with a Regional Occupational Program-sponsored CNA program. The CNA

program prepares people for the LVN program if they are interested in advancing further.

The PIC has funded the program with $200,000 to $250,000 for each class, depending on

the number of participants. The PIC pays for tuition, books, liability insurance, uniforms,

board fees, initial LVN license fees, and a part of childcare and transportation when needed.

The LVN Program — Training and student support

Students enrolled in the LVN training program attend school three days a week for eight

hours each day. Emanuel encourages the students to work as CNAs part-time during their

training, which, as Black explains, has many benefits. First, students begin to see their

work differently, and then they begin to evaluate their roles in nursing. Students are also

encouraged to choose a mentor at their workplace.

The program’s curriculum consists of three levels. The first level lasts 23 weeks with

instruction in anatomy, the fundamentals of nursing, pharmacology and psychology.

The next 29 weeks consist of medical/surgical nursing with an emphasis on the major

body systems and nutrition. Patient care plans are developed with an emphasis on the

body system under study. In level three, the final 20 weeks, students continue with

medical/surgical nursing as well as reproductive, maternal and child health, and a

leadership component. There is a 32-hour experience managing a clinical team as well.

Students practice various nursing team functions, such as identifying patient needs,

administering medications, making changes to patient care plans, reviewing lab tests

and results, and making rounds with physicians.

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The unique leadership component of the program occurs during the third level.

This 12-hour unit emphasizes professional attitude and behavior, and includes such

things as how to dress and behave professionally; how to develop and demonstrate job

interview skills; and how to develop a portfolio demonstrating one’s achievements and

experience. The attitude Black imparts to her students, particularly in this

component, is that “this time (in the LVN program) is gold, you can’t miss it.”

Black understands first-hand how important it is to impart this enthusiasm and

commitment to the students she has in the program. For the most part, students are

women who have been on welfare, and many are mothers who have not been successful

in school before. Black explains, “we need to teach such basic skills as how to study and

how to get along with other students.”

The Program’s success and future

Black attributes the success of the program to the leadership component of the curriculum

and the body systems approach that is used to organize the curriculum. She explains that

this approach may be considered old-fashioned in some nursing education circles today,

but she finds that it matches the needs of their student population. “Other curriculum

approaches require more integration of facts and materials, but our students need to learn

things system by system to build their knowledge,” Black explains.

With the step-by-step approach, students learn individual aspects of patient care.

For example, when studying the cardiovascular system, students are placed in the

cardiovascular unit where they learn about the cardiovascular system itself, the laboratory

tests performed for patients with cardiovascular conditions, the medications commonly

prescribed and the nursing care provided to these patients. And with each unit, students

receive first-hand experience with patients who have health problems with the particular

body system under study.

While they survey their students formally to learn about their post-graduate

placements, informally, they also maintain close-knit ties. Black knows where most of

her graduates are currently working, and says they are averaging $10 to $15 in hourly

wages, higher wage rates than some of the other JTPA program graduates. There are 80

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successful graduates from the program to date. Many, Black says, see further nursing

education and advancing to RN licensure as a longer-term goal. Almost half of the

graduates have started a program to prepare them to become a registered nurse (RN).

Black knows that five or six have already achieved this goal.

3. EMERGENCE OF COMMUNITY-BASED TRAINING PROGRAMS

In California, community-based training programs have become an increasingly

important alternative for meeting the demands of care delivery and the needs of workers

entering careers in allied and auxiliary health. Many of the programs, funded by private

foundations and the government, include partnerships between educational institutions,

care delivery and/or community-based organizations. Persons interested in community-

based training programs can receive training in a variety of allied and auxiliary health

occupations such as certified nursing assistant, medical assistant, home health aide and

health information technician.

Not only do they meet the training needs of care delivery, community-based training

programs often provide necessary services to the population they train. Many of the programs

offer a training alternative for persons exiting welfare and entering the job market.

Therefore, it is crucial to provide services to this population to help decrease or eliminate

certain barriers to employment. Such services may include financial assistance, remedial

education courses, childcare and transportation. Both the Gateway Program and the Service

Employees International Union Certified Nursing Assistant training program provide

special services to assist participants who are leaving welfare and seeking employment. These

services, described in Service Employees International Union CNA Training Program are crucial for

ensuring that participants are able to overcome all major employment barriers and succeed

in their training and job.

Some community-based training programs have been developed in order to meet

immediate needs and labor requests by local care delivery organizations. SEIU Local 250 in

Oakland, California developed a CNA training program that will help meet these demands.

This program has helped a local employer meet recruitment and retention needs, and

provided training opportunities to welfare recipients.


200 Service Employees International Union CNA Training Program

Due to a tremendous need for certified nursing assistants (CNA) in long-term care

institutions, local long-term care organizations have turned to the union to help train people.

The Service Employees International Union Local 250 has established a CNA training

program which is currently funded through the Job Training Partnership Act (JTPA)

Title IIA monies through the Oakland Private Industry Council and will be purchased

as a fee-for-service program through the Welfare-to-Work program. Joan Braconi, Program

Director, explained that the program began in August 1998 and has graduated 14 participants

— all of whom received employment as CNAs following the completion of the program.

SEIU recruits participants by publishing stories in the union newsletter, posting flyers at

local community organizations and by listing the program with the Oakland PIC. Most of

the participants in the training program are persons seeking to get off of welfare or they

must have a low income and be an Oakland resident.

Persons who qualify for the program receive 10 weeks of training and a guaranteed

job at the Lenox facility upon completion and certification. Upon entering the program,

trainees participate in a two-week job readiness course provided by the union. This portion

of the training provides information on interview skills, resume writing, job expectations,

employees’ rights and responsibilities, a background of the health care industry, diversity

issues, money management, medical terminology and basic study skills.

After completing the job-readiness training, participants are sent to the local Lenox

facility where they receive on-the-job CNA training. Participants are required to complete

40 hours a week of training for 8 weeks. However, during this period, all participants receive

a regular CNA salary. This training provides participants with the skills necessary to obtain

a job as a CNA in this facility and with the knowledge to pass the state certification exam.

Following completion of this program, all participants are offered CNA positions at a

Lenox facility.

In order to ensure that participants are able to complete the training, SEIU provides special

services to overcome any employment barriers. For example, the union provides assistance

with childcare and transportation; offers tutoring on basic reading, writing and math

skills; and offers counseling to assist with conflict management or other personal issues.

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This program has been beneficial to all partners and has not only provided training and

job opportunities, but has also helped to foster a healthy relationship between the union, the

trainees and the employer. In the past, Lenox has had difficulty recruiting, training and

retaining an adequate CNA staff. Through this program, Lenox has relinquished their

recruiting responsibilities and, due in part to the special assistance provided by the union,

Lenox achieved a 100 percent completion rate for the first class of participants of the SEIU

program. The program has also been beneficial to the union because it creates positive

relationships with local employers, has allowed participants to understand the benefits of

union membership and has supported a pro-union attitude for these participants.

Not only has this program helped the union and the employer, it also has had a

significant impact on program participants. Ms. Braconi emphasized that for many

participants this opportunity has changed their lives. SEIU has provided them with an

opportunity to get off welfare and take the first step towards self-sufficiency. This program

has provided them with self-esteem, training and most importantly employment.

The Gateway Program Provides Training Alternatives for Allied and Auxiliary Health Careers

City College of San Francisco (CCSF) in collaboration with Jewish Vocational Services of

San Francisco (JVS) provides a Gateway Program for California welfare recipients to gain

employment in a skilled health care position. The multiphase program first gives participants

the background preparation to enter their choice of health care training programs, the

students then enroll in a health care certificate program at City College. Finally, additional

training is provided to enhance job readiness and employability skills. The purpose of the

program is to help students find and hold a job after training. The program is funded by the

Hewlett Foundation and CCSF and will admit 29 students in June 1999.

JVS will first recruit and screen all applicants who must possess a high school diploma or GED

and meet low-income requirements. To assist participants to overcome the barriers that may

have previously prohibited them from employment, a number of other services are provided:

(continue)



• A 12-week academic and job-readiness training at CCSF focused on preparing

students to enter college-level health care training programs;

• Entry into a year-long study in a health care certificate program at CCSF;and

• A full-time career counselor from JVS that tracks participants through the program,

placing them in a career after the program is completed.

Administered at CCSF, the first component of the program prepares students to enter

regular CCSF health care courses. This 12-week module provides students with study

skills, a basic review of academic skills (math, reading and science), training in computer

literacy and medical terminology and job-readiness skills. At the end of the 12-week

course, students are placed in a CCSF health care training program. These CCSF programs

provide certificates to become a cardiovascular technician, EKG technician, emergency

medical technician, health information technician, medical assistant, home health

aide, certified nursing assistant or pharmacy technician. At the same time, JVS provides

career counseling and job placement services as well as assistance with employment barriers

such as transportation and childcare.


D . O N - T H E - J O B T R A I N I N G

On-the-job training (OJT) has always been an important aspect of health care provider’s

education, but given the increasingly complex demands of the health system, on-the-job

training has become all the more important. This section examines the factors that contribute

to the existence of OJT, the scope and variety of training provided and the implications for

unlicensed assistive personnel in terms of transferability and documentation of skills learned on

the job. Finally, the implications for educators are discussed, as care delivery organizations are

increasingly providing training in-house rather than working with local educational systems.

1. CHANGING EMPLOYER NEEDS

Given the transformation of health care, employers increasingly demand that their workforce

demonstrate competence in an evolving set of skills. Some of these skills include clinical and

technical abilities required for particular health care occupations and professions related to

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technological developments. However, they also include interpersonal and communication

skills that allow providers to interpret and convey information, work in interdisciplinary teams

and relate to diverse patient populations. Many of these skills were introduced in detail and

presented according to health care setting and occupational category in Section VA of this report.

2. SCOPE AND VARIETY OF ON-THE-JOB TRAINING

In conjunction with skill deficits, employer expectations, and changes occurring in

educational systems, the health care delivery sector is developing both formal and informal

training systems for their allied and auxiliary workforce. Such on-the-job training not only

prepares allied health care personnel to perform specific clinical and support roles in care

delivery settings, but it also instructs auxiliary health care personnel who have not received

job-related training in the educational sector. Many types, models and goals exist for on-

the-job training. Two specific types of training, system-wide orientation and department or

skill-specific training, are described in the following paragraphs.

The first type of training includes general training to orient new employees to a facility’s

systems and organizational values. In the health care industry, orientation also incorporates

instruction for health and safety procedures to which all care delivery settings need to adhere,

including practices for infection control, hazardous waste handling, and using and disposing

of safety needles. This orientation training may also include more general issues such as

customer service orientation, cultural diversity and ethics in a health care environment.

(See Putting on the Ritz and Tenet Health Care Corporation’s Ethics Program in Section VA.) Many of the

survey respondents indicated a great deal of training is required for orientation purposes.

The second type of training, department-specific training is used to instruct personnel in

their respective departments on procedures, equipment and skills. This training can prepare

new employees to “get up to speed” and work in the full capacity of their position. The types

of training provided to nurse aides and certified nursing assistants (CNAs) exemplify

department-specific training. Project interviews found that nurse aide training varied from

facility to facility and often was individualized. Generally, RN or LVN personnel train nurse

aides and CNAs between two to ten days. Some type of mentoring or pairing of the new

employee with another nursing staff member often follows initial orientation training. This

mentoring tends to continue until the new employee has been evaluated and a level of

confidence is established, after which the employee may work independently.

Moreover, department-specific training may also include instruction on new skills such

as rehabilitation therapy, phlebotomy or electronic medical records. This training, also

called in-service training, includes ongoing demonstration of specific skills and

competencies. In-service training in skilled nursing facilities (SNFs) often provides new or

ongoing skill training. Hospitals and SNFs offer a variety of training that depends on

factors such as the presence of an on-site SNF, staff composition (composed exclusively of

CNAs or nurse aides, or a mix of both) and their participation as a clinical training site.

Some of on-the-job training is mandated by state requirements such as Title 22. This

code of law specifies necessary education and training on skills related to direct patient

care across health care settings. In addition, care delivery institutions set internal

proficiencies or skills by which they regularly instruct and evaluate employees. These skills

may include how to use particular kinds of needles, thermometers, or other types of

instruments and equipment; or they may relate to the particular types of patients cared

for in a facility such as communicating with dementia patients, respiration, mobility or

transport practices.

3. LOCATION OF TRAINING

Most often, on-the-job training is conducted in-house at the care delivery institution.

Department supervisors and other senior level personnel provide on-the-job training

in these circumstances. In some instances, partnerships are formed between a care delivery

and an educational institution to fill the task. These partnerships are initiated by employers

or educational leaders to train employees in particular skills, such as performing

phlebotomy or respiratory therapy. In the Project’s hospital sample, smaller hospitals

differed qualitatively on how to conduct on-the-job training from the larger hospitals.

Smaller hospitals reported that they conduct training in-house whereas larger hospitals

reported options to conduct training in-house as well as to partner with local community

colleges or other educational institutions.

Among the Project’s sample of SNFs, 12 of the 15 respondents indicated that they conduct on-

the-job training in-house. Internal staff, such as directors of staff development or directors of

nursing, are responsible for conducting this training. And while much of CNA training appears

to be standardized across the facilities that the Project interviewed, respondents also described

how training is individualized to ensure CNAs have confidence in performing care-related tasks.


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Many facilities described additional training beyond the state and federal requirements that is

provided on an ongoing basis to meet the needs of their particular residents.

For particular systems or equipment, training may be provided by equipment manufacturers

to department supervisors who in turn instruct their personnel in-house. This is particularly

relevant in clinical laboratories where instrument manufacturers can require their own

training and certification. Another example is for new medical records systems. Once the

manufacturer trains a supervisor or technologist, they in turn train their staff who will use the

new equipment, instrument or system.

4. TRANSFERABILITY AND DOCUMENTATION OF SKILLS LEARNED ON THE JOB

The transferability of skills acquired from on-the-job training from one care delivery

setting to another is of particular concern. The Project’s interviews made clear that the

experience of previous employment and training is highly valued, as many hospitals seek

to hire applicants with experience from either the same or another health care setting.

Yet, additional training in the new facility is still necessary. Furthermore, without

standard training requirements for many auxiliary occupations, some prior training may

not be recognized in a new facility.

Another important issue is the requirement to document and demonstrate training.

As noted in the regulatory section of this report (Section IIE), changes in regulation on the

occupational and facility levels often result in new requirements. These requirements

translate to an increased amount of time spent on documentation of on-the-job training.

Employers will always need to provide both system-wide orientation and department-specific

training in order to familiarize a new employee with the particular systems, equipment and

procedures of a facility. While some of the Project’s survey respondents said that uniform

systems and programs exist across care delivery organizations, a lack of standardization

continues to drive the need for on-the-job training.

5. IMPLICATIONS AND SIGNALS TO EDUCATORS

Given that many care delivery institutions conduct on-the-job training in-house, a great

deal of variation exists among the types of training and the skills imparted. While survey

respondents described common skill checklists, systems and equipment that are used across

organizations in the industry, there were also indications that organizations had unique


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crosstraining or combinations of positions that affected the amount and type of on-the-job

training conducted. With this variation, it is difficult to recognize the training and skills

gained as employees move from one organization or setting to another. Furthermore, as

described in Section IIE on regulation, the care delivery institution carries full

responsibility for the competency of particular auxiliary occupations that receive all of their

training on-the-job. If care delivery institutions continue to rely more on on-the-job

training to meet skill demands, there will not only be less standardization of skills and

training, but also an increased responsibility and burden on the institutions.

The effects of increased on-the-job training suggest there is a need for other sectors to

support care delivery in providing training. Those care delivery institutions surveyed by the

Project that did utilize outside resources for conducting on-the-job training often

indicated that consultants and professional associations were used in addition to educational

institutions. For example, Kaiser Permanente contracted with a management firm to

conduct on-the-job training for its medical assistants during its redesign of adult primary

care. This suggests that when care delivery organizations assess their on-the-job training

needs, industries other than the educational sector are prepared to meet care delivery needs.

This report has provided a detailed overview of health care delivery and education in

California, the allied and auxiliary workforce and the systems through which these workers

are trained for careers. It has identified challenges facing health care and education and

proposed that the problems exist, because these sectors and the workforce itself have not

worked as cooperatively or collaboratively as they could. This final section of the report

turns to how partnerships among leaders in care delivery organizations, educational

institutions, labor unions, and individual workers could not only improve the work

environment for allied and auxiliary health workers but the health care system as a whole.

As the health care system continues to evolve, the pressure to make changes in the ways

health professionals are educated, utilized and regulated will grow. This report describes, for

example, how the care delivery system is repositioning the allied and auxiliary workforce to

meet immediate demands of reducing cost and increasing productivity through such policies

as multiskilling and the transfer of work to the least costly provider. Compounding efforts to

reposition health care workers, regulatory standards that guide the practice of allied and

auxiliary workers are disconnected from the realities of the modern care delivery system.

Limiting benefits and wage rates are other ways to reduce cost within health care. Limiting

wage increases has continued even though responsibilities of some positions have often

increased significantly. Among the Project’s findings, care delivery organizations also cited

mounting cost pressure as barriers to supporting much needed clinical training sites. While

these cost issues and challenges continue, California’s population will continue to diversify,

increasing the need to train and recruit culturally competent providers with adequate language

and communication skills. In addition to these skills related to diversity, the care delivery system

struggles to find workers with specific skill sets, critical thinking ability and a strong work ethic.

While many health care delivery institutions and systems face issues of cost, diversity and skill

deficits, they also recognize the need to compete on the basis of quality in addition to cost.

However, the Project found few organizations that were willing or able to offer a human

resources initiative tied to a quality strategy. While some innovative care delivery organizations

were profiled in the report, many do not have, or do not include the allied and auxiliary health

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C O NC L U S I O N S / D EV E L O P I NGP O L I C I E S forS U S TA I NA B L E C H A NG E

S E C T I O N IX


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care worker in a strategic quality improvement process. Moreover, many of these organizations

cited problematic turnover rates, suggesting that work conditions may not be sustainable.

The report has also described how the educational sector has not offered a product that

meets the needs of employers or students. In addition, educational institutions face unique

challenges, including the need to better prepare a student population that is growing in

number and diversity, recruit for and improve faculty/teacher training, evaluate and

expand new models of education, and increase accountability to education’s consumers.

Furthermore, these challenges for care delivery and education are occurring during a

dynamic time when the society overall is changing how work is organized and structured.

The service sector, of which health care delivery is a part, values a workforce that is

crosstrained, flexible and willing to continually upgrade its skills.

With these issues and challenges in mind, the Project outlines seven key recommendations

for change with specific actions for participants in the educational, care delivery and labor

sectors. Two themes permeate these recommendations. The first is the necessity of forming

partnerships both within and between sectors, including the care delivery, education, labor

and corporate sectors. The second key to success is the collection of data in order to evaluate

the outcome of the recommendations being made.

RECOMMENDATIONS f o r THE ALLIED AND AUXILIARY HEALTH CARE WORKFORCE

Recommendation I: Define skill requirements that are aligned with care delivery


competencies, for the allied and auxiliary health care workforce. Require health



While entry-level national skill standards exist, the rapidly changing health care system will

require employers to continually identify basic skills needed in the allied health workforce.

Leaders in care delivery organizations need to arrive at consensus on core skills and

competencies in order to better inform education and labor partners on curriculum

development. Care delivery organizations must partner with educational institutions to

identify priority skills that are lacking and identify existing programs that teach these skills.

These partnerships can develop new or replicate existing successful programs to support

the teaching of these skills. Moreover, a process by which these skills and standards can be

updated must be established. To teach these skills may require the additional provision of

staff development opportunities.

Care delivery organizations need to recognize the essential role they have in teaching

clinical and technical competencies as part of health education and include this

provision in their productivity standards. Therefore, within care delivery organizations,

existing resources need to be identified and utilized to support training opportunities.

For example, individual care delivery organizations might partner together in order to offer

clinical/practical training that supports the achievement of skill requirements.

Educators must work in partnership with care delivery organizations to identify and update

curriculum that meets employers’ standards. Health care skills taught in the educational setting

need to translate into competencies that must be demonstrated in care delivery. K-12 and

postsecondary educators need to work in partnership along with care delivery organizations to

identify and implement core skills and competencies applicable to the auxiliary health care

worker as well as competencies to prepare students continuing on to postsecondary educational

programs. Partnerships within education must aim to ensure that these fundamental

competencies are achieved and define their success in terms of providing job and life skills to

students who can continue in education and/or become productive workers.

Labor will also need to participate actively in the process of identifying skills and

competencies and ensuring that the workforce maintains an adequate skill base. To support

this process, labor must educate their members about the skills needed to maintain, succeed

and/or advance in their current occupations/professions and organizations. Furthermore,

labor should encourage polices, such as offering paid time-off to attend work-related

training, that reward individuals who display motivation, continue to learn and improve

their job performance. In order to support these workforce goals and be equitable, the

policies need to define and publicize uniformly the criteria for such rewards.

Recommendation 2. Expand training and awareness to better prepare the

workforce for delivering health care to an increasingly multicultural society.

First, define and develop competencies for delivering culturally sensitive care for

all allied and auxiliary workers. Second, actively support hiring and training

a more diverse workforce.

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210 Minimal awareness and preparation exist for delivering health care to an increasingly

diverse population in the nation and particularly in California. There is a need to extend

beyond linguistic competencies, which address language issues between patients and

providers, to cultural competencies that broaden the understanding of delivering care to

patients with diverse health care needs relative to age, culture, race/ethnicity, gender,

physical condition, religion, etc. Care delivery organizations must take a dual approach to

addressing diversity. First, organizations need to ensure that all providers deliver culturally

competent care. For example, medical interpreter programs can offer cultural sensitivity

and communication training for bilingual health care workers. Another example is

multicultural training programs that expose all allied and auxiliary health care workers to

issues that may arise when providing support and care to patients from diverse backgrounds.

Second, expanding recruitment efforts to diverse populations will enable care delivery

organizations to meet the needs of the diverse patient population. Both efforts will require

care delivery organizations to partner with educators. These partnerships should first define

and develop training models to teach cultural competence and then evaluate the success of

these models. These partnerships also must establish feedback mechanisms and other

guidance programs to support the retention and success of a diverse workforce.

Preparation for serving California’s diverse population must begin before individuals

enter the workforce. To do so, educators must also take a dual approach to addressing

diversity. First, educators need to prepare all health care providers with the skills to provide

culturally sensitive care. The foundations for these skills and competencies must be

incorporated into the K-12 curricula and the specific skills and competencies must be

incorporated into allied health training curricula. In order to expand training and teach

new cultural competencies, innovative teaching models and new approaches often need

to be developed and utilized. Educational and care delivery organizations should

partner to create professional development programs to build faculty/teacher and

management/supervisor capacities to teach skills using new approaches.

Second, educators need to actively recruit a more diverse student base reflecting

California’s diversity. Educators can promote health care as a desired career in order to

support recruitment efforts. To sustain a diverse student base, educators need to

provide programs to support the successful matriculation of students through health

training programs.


Labor should participate in diversity efforts by providing ongoing skill enhancement

opportunities related to cultural competencies and encouraging individuals to take

advantage of them. Labor should also encourage the advancement of underrepresented

minorities in the health professions, and assist education and employers in understanding

and providing for the needs of culturally distinct groups.





Conditions of employment need to be aligned with the changing nature of work and

changing demographics of the workforce. To create these work environments, care delivery

organizations must promote high quality, flexible standards that value a diverse, productive

and healthy workforce. First, fundamental issues such as problematic turnover and

ineffective training need to be addressed. Care delivery organizations can offer improved

employment compensation and conditions for entry-level workers. For example, care

delivery organizations, particularly in the long-term care setting, can increase wages for

certain auxiliary occupations, but to do so, will need to assess turnover cost and reduce cost

in other areas. Implied is the need to measure and evaluate these costs in order to

demonstrate savings and other improved outcomes. Increased wages will also require workers

to arrive with a set of basic customer service and core health care competencies.

Second, to improve training opportunities and assist all workers in acquiring a portfolio

of skills, care delivery organizations can offer skill improvement opportunities and other

resources in addition to traditional career advancement. Skill improvement opportunities

can include training in new skills related to patient care and support, and also broader

employment skills such as training in computer, oral communication, and language skills,

as well as diversity awareness and customer service orientation. Organizations can also offer

opportunities to move into new positions in other departments within the organization.

To be flexible, care delivery organizations should allow the workforce some choice

regarding their participation in these opportunities. Care delivery organizations can

also be flexible by offering alternative work schedules to allow workers to take advantage

211



of training opportunities. By offering improvements in wages and training, and some

flexibility in work conditions, care delivery organizations can create a healthier work

environment in which the workforce is valued, better prepared and sustained.

For the workforce to arrive with a core set of competencies, educational institutions need to

better prepare students for the realities of work and the care delivery system. To do so, education

needs to impart all students with a basic work ethic and general job skills to remain employable.

In addition, education needs to impart all students with a core set of health care competencies

with input from local care delivery organizations. These recommended actions, which relate

to Recommendation I, convey how education must follow and support students beyond the

time they are in educational programs to ensure their success in the workforce. To attain

these goals, education should retrain faculty in how to prepare students to remain employable

in the workforce and to be successful in health care delivery.

Labor unions need to recognize the expanding skill base required in entry-level workers in

conjunction with the increased wages and improved employment. Labor unions should

encourage and facilitate ongoing skill development for all workers. In particular, labor

should encourage entry-level workers to participate in crosstraining and career advancement

opportunities. Part of the task of creating a new health work environment is opening up

certain workforce structures and creating a flexible work environment. Labor unions

should assist care delivery organizations in creating this flexible work environment, by

opening up some of the union’s structures.

Recommendation 4. Position the allied and auxiliary workforce in health care delivery’s

strategic process of improving the quality of patient care.

Care delivery leadership must possess greater awareness of the care and service contributions

made by the allied and auxiliary workforce. First, leadership in care delivery must recognize

and advocate for the significant role of allied and auxiliary health care workers in

providing health care services. Regardless of the care delivery orientation implemented by

an organization, allied and auxiliary services must be tied to the overall objectives of care

delivery organizations, including cost, health care quality and patient satisfaction. Research

efforts need to measure and demonstrate the contributions and improvements to patient

care provided by the allied and auxiliary workforce.


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Educators for individual occupations and professions must partner together to provide

leadership for the role that allied and auxiliary health providers collectively contribute to the

quality of patient care. Current educational structures support the teaching of individual

occupations and professions for discrete tasks. These structures do not encourage educators

to relate individualized training to a continuum of care, interdisciplinary care teams, or a

process for the delivery of services that are essential in care delivery. Faculty/teachers in

education might be required on a continuing basis to job shadow or gain experience in the

profession for which they prepare students. From this experience, leaders in education can

change institutional structures, making them more flexible, in order to teach and demonstrate

how individual occupations work in teams with other providers and how each contributes to

patient care. Allied health education is obligated to provide the conceptual and research

leadership associated with these tasks. For example, educational experiences can be

restructured to provide interdisciplinary and team-oriented training. These new structures

also can allow educators to teach a comprehensive set of core curriculum. Finally, within

these new structures, educators should provide training on research methods utilized in

quality improvement processes.



Across care delivery, education and labor sectors, all organizations should strive to build

and sustain programs that incorporate allied and auxiliary workers in the quality

improvement process. Once the allied and auxiliary workforce is positioned in health

care delivery’s strategic process of improving the quality of patient care (see

Recommendation IV), these programs need to continually strive to meet quality goals,

and to demonstrate the value of this workforce’s contribution to delivering quality care

and service. Furthermore, funding needs to be available so that these contributions and

goals can be evaluated. The essential element needed to make this transformation of

work and build these work structures is flexibility. Offering alternative work schedules,

feasible training opportunities, variations on new roles and crosstraining, and offering

employees the opportunity to give input are ways organizations in all sectors can

demonstrate flexibility.

213




214 Care delivery organizations must value and create ways to empower workers to deliver

high quality care and service. Part of this task is for organizations and particularly human

resources managers to provide workers with the tools and training to deliver quality services.

Another part is to invite input from the allied and auxiliary workforce into the change and

quality improvement processes. Care delivery organizations need to identify existing resources

and systems that support programs and continually measure outcomes of these programs,

including cost and quality of care. Care delivery organizations should restructure personnel

reward systems that are based on demonstrating competencies and contributions as part

of the quality process.

Education should develop new reward systems for innovations in curriculum development

and teaching by faculty/teachers as part of the quality improvement process. It will be

essential for deans and leaders of allied health programs to provide the direction, leadership

and support to build such systems. The necessary authority, skills and/or rewards for

performance may not exist at the leadership level of most allied health programs; therefore,

these may first need to be promoted by the institution’s central administration.

Efforts to transform work and work structures will not be successful without the full and

early participation of organized labor. The commitment to change and quality improvement

of the allied and auxiliary workplace will inevitably lead to new, different and perhaps

fewer jobs. If this is so, labor needs to take a leadership role in assuring that workplace

redesign provides something for every worker. Overall, change and quality improvement in

health care work mean organizations, unions and workers alike need to share responsibility

for quality. Therefore, labor unions also need to support individual awards for excellence

based on defined criteria and the inclusion of job performance measures, as well as seniority

guidelines for worker evaluation. Also, labor’s view of job performance needs to broaden

beyond an individual’s performance within an organization.




Allied and auxiliary health care workers may not take advantage of career advancement or job

enhancement opportunities. To increase participation, care delivery organizations must


create environments that positively support and encourage the development of new skills

and capabilities. To do so, care delivery organizations must conceptualize and offer new

skill enhancement and crosstraining opportunities in addition to traditional career

advancement opportunities. Care delivery organizations must ensure all allied and auxiliary

workers are continually made aware of such opportunities, and encourage employee input

when opportunities are taken.

Educational institutions are not exempt from the changing realities of work and careers, and

must instill in students the responsibility throughout their careers for continually

upgrading their skills. To support this, educational institutions might implement tracking

programs to follow students after completion of their education. In addition, educational

institutions and care delivery organizations need to collaborate in order to learn and

understand each other’s requirements for all types of training and career enhancement

opportunities. With these partnerships, educational programs should be structured and

offered in ways that are attractive and feasible for the worker. New educational models that

impart these concepts and values must be evaluated to identify successful models.

Workers need to possess a greater understanding and awareness of their own role in career

enhancement. Educators, unions and care delivery organizations have a shared responsibility

to instill an understanding in workers about the changing realities of work and careers in

the next century. The responsibility is to convey that automatic advancement no longer

exists and that education and training do not end when individuals enter the workplace.

Labor should take a stronger, proactive role by sponsoring educational opportunities and

encouraging members to participate in them.





Allied and auxiliary workers may not work to their full skill capacity and/or may provide

overlapping services within occupational clusters or with other providers. First, research

efforts need to assess the extent to which these factors exist, and the impact they have on

quality of care, cost, and workforce and patient satisfaction. The findings from this research

215




216 should then determine appropriate training and use of allied and auxiliary health care

workers so that they can practice to their full capacity from a worker perspective and with

high quality and efficiency from a patient and care delivery perspective.

Regulatory scopes of practice and state practice acts need to be flexible enough to allow allied

and auxiliary health care workers to practice to the fullest of their ability. For example, this

flexibility can allow for multiskilling, broader scopes of practice or elimination of exclusive

scopes of practice depending on the skills on which practitioners are trained. To create this

flexibility, regulators and professional associations should support research efforts and use the

findings to substantiate changes to regulation. All levels and types of regulators must work

collaboratively to overcome barriers to full, effective utilization of allied and auxiliary workers.

Care delivery organizations and others need to collect and monitor quality data to ensure

that new and innovative staffing configurations provide the highest quality of patient care.

These research efforts should assess the effect of particular allied and auxiliary worker

services on outcomes such as workforce productivity and satisfaction, as well as patient

satisfaction and care. Organizations must work collaboratively with the professions to

achieve flexible regulatory standards for allied and auxiliary workers. These tasks may require

that further staff development and training be provided to care delivery employees.

Educators must stay current and knowledgeable about regulation and data collection and

other research needs. Educators must take a leadership role in emphasizing allied and

auxiliary health care research and data collection efforts. Educators must prepare the future

workforce with the skills, competencies and roles that reflect updated scopes of practice and

address both current and future needs of care delivery. To do so, education must provide

for staff development so that faculty can teach these updated skills, competencies and roles

for health care practitioners.


METHODS FOR CARE DELIVERY RESEARCH

Qualitative Research Methods — Care Delivery Surveys, Interviews and Focus Groups

Methods for the qualitative approaches taken in the care delivery research are described

here. First, informal interviews were conducted to confirm and clarify issues identified in

the literature review. Keeping these issues as the focus, self-administered, multiple-choice

response surveys and semi-structured, open-ended interviews were developed for four

health care delivery settings: hospitals, long-term care facilities, home health agencies and

clinical laboratories. Core questions regarding institutional change, contracting out clinical

and support services, staffing temporary employees, workforce benefits, and workforce

training and educational assistance were standardized and then adapted to four setting-

specific versions of the survey. For clusters of occupations employed in each setting, questions

on the quality, quantity and experience of the applicant pool, as well as turnover issues and

needed skills, were formulated.

The Project staff, advisory committee members and other experts reviewed the draft surveys

and interviews. In addition, the surveys and qualitative research protocol were reviewed and

approved by the UCSF Committee on Human Research. Next, the questionnaires were pilot

tested in representative care delivery institutions and respondent feedback was incorporated

into the final surveys. For each version of the survey and interview, consultation was sought

for appropriate methods to invite institutions to participate.

For hospitals, skilled nursing facilities and home health agencies, random samples of

institutions across the State were generated using the Office of Statewide Health Planning and

Development (OSHPD) published databases. The selected hospitals, skilled nursing facilities

and home health agencies were invited to participate in the survey and interview. For clinical

laboratories, representative institutions across the State were selected in consultation with the

Department of Health Services — Laboratory Field Services branch using a state database for

registered and licensed laboratories. Available demographics of all institutions and those that

participated are presented below. In addition, maps displaying the geographic location of

survey participants and the distribution of all hospital facilities, skilled nursing facilities and

home health agencies across California counties are presented at the end of this appendix.

217



A P P E N D I X A

Care Delivery Sample — Skilled Nursing Facilities

From the 1996-97 long-term care disclosure report database available at the time of

sampling, 1,137 (or 90.6 percent) of the 1,255 long-term care facilities were skilled nursing

facilities (SNFs). From these 1,137 SNFs, 30 were selected randomly. A total of 5 agreed to

participate in the survey and interview process (representing a 16.7 percent response rate) in

addition to 10 SNFs located in the Bay Area that agreed to pilot test the survey and interview.

Care Delivery Sample — Hospitals

There were 425 short-term general hospitals in the 1995-96 OSHPD database available at

the time of sampling, representing 73 percent of all hospitals in California. From these 425

hospitals, 80 short-term general hospitals were selected randomly. From the sample of 80

hospitals invited to participate, 19 completed the survey and 18 completed both the survey

and interview, representing a 24 percent response rate. The demographics of these hospitals

are presented in Exhibit A1.


218


E X H I B I T A1: Population, Random Sample and Participating Short-term, General Hospitals

Number 425 80 19

Profit Status– For-profit 111 (26.1%) 25 (31.3) 6 (31.6%)Non-profit 233 (54.8) 44 (55.0%) 8 (42.1%)County 81 (19.1%) 11 (13.8%) 5 (26.3%)

Size (no.of staffed beds)– Mean 73 169 181Less than 100 149 (35.1%) 27 (33.8%) 7 (36.8%)100 or more 276 (64.9%) 53 (66.2) 12 (63.2%)

HOSPITAL DEMOGRAPHICS CALIFORNIA SHORT-TERMGENERAL HOSPITALS*

RANDOM SAMPLE OFHOSPITALS

PARTICIPANT HOSPITALS

*OSHPD. Summarized from Individual Hospital Financial Disclosure Reports. 1995-96.

E X H I B I T A2: Population, Random Sample and Participating Skilled Nursing Facilities

SNF Demographics CALIFORNIA SNFs* RANDOM SAMPLE OF SNFs PARTICIPANT SNFs

Type of care Long-term care facilities Skilled nursing, 90% free standing Skilled nursing, all freestanding

Number 1,137 SNFs 30 51,255 long-term care (plus 10 pilot test)

Profit status– For-profit 1,086 (86.5%) 22 (73.3%) 14 (93.3%)Non-profit 165 (13.1%) 5 (16.7%) 1 (6.7%)Government 4 (0.3%) 3 (10.0%) 0 (0%)

Size (no. of beds) – Mean 99** 82 90Less than 100 877 (69.9%) 23 (76.7%) 9 (60.0%)100 or more 378 (30.1%) 7 (23.3%) 6 (40.0%)

*For all comparable long-term care facilities. Labor Productivity Summary for Report Periods Ending January 1, 1997 throught December 31, 1997. OSHPD. 1998.**For all long-term care facilities with individual bed size information available. OSHPD. 1997.

E X H I B I T A4: Representative and Participating Clinical Laboratories

REFERENCE CLINICAL LABORATORIES REPRESENTATIVE LABS PARTICIPANT LABS

Number 16 5

Profit status– Uknown 13 0For-profit 2 4Non-profit 1 1

Volume of testing – 100,000 per year or less 9 2More than 100,000 per year 5 3Unkown 1 0

Care Delivery Sample — Clinical Laboratories

As the oversight agency for clinical and other laboratories, the Department of Health Services,

Laboratory Field Services branch was consulted in order to select a representative sample of

clinical reference laboratories across the State. There are approximately 15,000 laboratories in

California, including physician office laboratories, hospital-based laboratories and reference

laboratories. A total of 16 reference laboratories of various size according to annual volume of

testing were selected, and 5 agreed to participate in the survey, for a response rate of 29 percent.

Care Delivery Sample — Home Health Agencies

Representing the 1,247 home health agencies in California, 30 agencies were selected

randomly from the 1996-97 OSHPD database. From this random sample, current contact

information was verified for 27 agencies that were then invited to participate. A total of 8

agreed to participate, representing a 30 percent response rate.

219



E X H I B I T A3: Population, Random Sample and Participating Home Health Agencies

AGENCY DEMOGRAPHICS CALIFORNIA AGENCIES* RANDOM SAMPLE PARTICIPANT AGENCIESOF AGENCIES

Number 1,247 27 8

Profit status– For-profit 840 (67.4%) 3 (37.5%)Non-profit 359 (28.8%) (Not Available) 5 (62.5%)Government 48 (3.8%) 0 (0.0%)

Size (average annual no. of visits) For-profit 10,165 17,962Non-profit 21,146 (Not Available) 29,879Government 13.422

*OSHPD. Selected Home Health Agency Data Statewide Totals, 1996.


220 Qualitative Research Methods - Focus Groups

The literature searches and preliminary findings from surveys and interviews were reviewed

to identify central issues and questions to explore further in focus groups. This qualitative

approach was employed to meet the following objectives:

1. Explore workforce and ambulatory care issues for medical office groups from the

perspective of office administrators, clinical managers and medical records managers, and

2. Explore allied and auxiliary health care workers' perspectives on particular issues

including career mobility, multiskilling, flexible work schedules and reengineering.

For the allied and auxiliary health care worker focus groups, two groups of 12 individuals

each were held on January 20, 1999 at the UCSF Center for the Health Professions.

One group included individuals with limited patient contact and the other included

those workers with regular patient contact. Between the two groups, the participants

represented the following hospital departments: medical records, clinical support, laboratory,

physical therapy, psychiatry, radiology, environmental services, transportation, food service,

surgery and nursing. Of the total 24 participants, there were 10 men and 14 women.

The participant's tenure in their current health care positions ranged from 3 months to

over 30 years. The participants were recruited from 13 hospitals throughout the San Francisco

Bay Area using recruitment flyers posted at the facilities. Arthur Associates, using a

discussion guide and rating sheet, moderated both groups.


221



SAN BERNARDINO18

RIVERSIDE17

INYO2

KERN10

LOS ANGELES129

ORANGE38

SAN DIEGO25

IMPERIAL2

VENTURA8

SANTA BARBARA12

SAN LUIS OBISPO0

TULARE6

KINGS3

MONTEREY4

FRESNO11

MADERA2

MARIPOSA1

MERCED6

SANBENITO

1

SANTACLARA

12

SANTACRUZ

2

SANMATEO

10

SAN FRANCISCO

11

CONTRACOSTA

11

ALAMEDA14

SOLANO4

MARIN3

SONOMA9

NAPA3

SANJOAQUIN

7

STANISLAUS7

TUOLUMNE2

ALPINE0

MONO1

YOLO3

AMADOR1

EL DORADO2

PLACER2

COLUSA1LAKE

2

MENDOCINO3

GLENN1

BUTTE5

TEHAMA1 PLUMAS

4

SIERRA1

LASSEN1

SHASTA5

TRINITY1

HUMBOLDT5

SISKIYOU3 MODOC

2

DELNORTE

1

NEVADA2

YUBA1SUTTER

1

SACRAMENTO11

CALAVERAS1

0 to 2

3 to 7

8 to 16

17 to 38

129

Indicates location ofinterview participant

Source: Office of Statewide Health Planning and Development (OSHPD): Hospital Annual Fianancial Data, 1997.

E X H I B I T A5: Distributions of Hospital Interview Participants and California Hospital Facilities (1997) by County


222


SAN BERNARDINO53

RIVERSIDE50

INYO1

KERN15

LOS ANGELES405

ORANGE76

SAN DIEGO90

IMPERIAL3

VENTURA19

SANTA BARBARA16

SAN LUIS OBISPO0

TULARE13

KINGS3

MONTEREY16

FRESNO36

MADERA5

MARIPOSA0

MERCED8

SANBENITO

1

SANTACLARA

58

SANTACRUZ

12

SANMATEO

23

SAN FRANCISCO

19ALAMEDA

77

SOLANO526

MARIN215

SONOMA20

NAPA10

SANJOAQUIN

26

STANISLAUS18

TUOLUMNE0

ALPINE0

MONO0

YOLO7

AMADOR1

EL DORADO3

PLACER9

COLUSA1LAKE

3

MENDOCINO5

GLENN1

BUTTE12

TEHAMA3 PLUMAS

1

SIERRA0

LASSEN1

SHASTA7

TRINITY0

HUMBOLDT6

SISKIYOU2

MODOC0

DELNORTE

1

NEVADA5

YUBA1

SUTTER4

SACRAMENTO42

CALAVERAS2

CONTRACOSTA

33

Source: Office of Statewide Health Planning and Development (OSHPD): Long-Term Care Facility Annual Fianancial Data, 1997.

0 to 4

5 to 9

10 to 24

25 to 49

50 to 100

405

Indicates location of

interview participant

E X H I B I T A6: Distributions of Skilled Nursing Facility Interview Participants and California Skilled Nursing Facilities (1997) by County

223



SAN BERNARDINO71

RIVERSIDE58

INYO1

KERN26

LOS ANGELES457

ORANGE87

SAN DIEGO96

IMPERIAL9

VENTURA33

SANTA BARBARA16

SAN LUIS OBISPO0

TULARE13

KINGS4

MONTEREY25

FRESNO31

MADERA3

MARIPOSA3

MERCED10

SANBENITO

2

SANTACLARA

43

SANTACRUZ

9

SANMATEO

31

SAN FRANCISCO

29

CONTRACOSTA

29

ALAMEDA55

SOLANO10

MARIN11

SONOMA23

NAPA3

SANJOAQUIN

20

STANISLAUS12

TUOLUMNE5

ALPINE0

MONO0

YOLO5

AMADOR2

EL DORADO15

PLACER8

COLUSA1LAKE

4

MENDOCINO4

GLENN0

BUTTE15

TEHAMA3 PLUMAS

2

SIERRA0

LASSEN19

SHASTA8

HUMBOLDT9

SISKIYOU5

MODOC3

DELNORTE

9

NEVADA4

YUBA2

SUTTER7

SACRAMENTO51

CALAVERAS5

TRINITY1

0 to 4

5 to 9

10 to 24

25 to 49

50 to 100

405

Indicates location ofinterview participant

Source: Office of Statewide Health Planning and Development (OSHPD): Long-Term Care Facility Annual Fianancial, 1997.

E X H I B I T A7: Distributions of Home Health Agency Interview Participants and California Home Health Agencies (1997) by County


224

GLOSSARY OF TERMS

The following are definitions for terms used throughout this report which may have different

connotations depending on the context and reader. The aim is to define how each term is

used in the context of the California Twenty-First Century Workforce Project and this report.

Allied health care worker - The Project broadly defines these workers to include the traditional

200+ health professions and all personnel who provide therapeutic, diagnostic,

informational or environmental services in health care delivery settings. They may be

licensed, certified or registered, and provide either direct or indirect care and support

services to patients. Not included are physicians, pharmacists, optometrists, physician

assistants or nurses (nurse practitioners, registered nurses or licensed vocational nurses).

Auxiliary health care worker - The auxiliary worker is an even less well-defined group that can

provide environmental and other support services. Typically these workers are not licensed,

certified nor registered. These occupations are predominantly hospital-based.

Care delivery - Care delivery collectively refers to the health care sector, including the five

settings the Project focuses on: hospitals, medical groups, home health agencies, long-term

care facilities and clinical laboratories.

Career mobility - Career mobility is sometimes referred to as job advancement. Career mobility

can mean that there are clearly defined career pathways for advancement to positions with

increased responsibility, skills and compensation.

Education - Education collectively refers to the educational industry, including K-12 and

postsecondary levels of education as well as community-based organizations and others that

provide educational services to the workforce.

Flexible workforce - A workforce that meets the needs of care delivery employers by being

multiskilled, cross-functional and able to work varying schedules.


A P P E N D I X B

Flexible work schedules - Flexible work schedules can mean several things. Sometimes flexible

work schedules allow workers to choose the days or times of shifts that they prefer to work.

This might mean working three 12-hour shifts for 3 consecutive days, and then having 4

days off, or it could mean working only in the mornings or afternoons. These types of

flexible schedules may help workers balance other responsibilities in their lives. Sometimes

flexible work schedules means that if patient census is low, workers may be sent home early,

often without pay. Flexible shifts can also mean that shift times change every two or four

weeks, with or without the worker's input.

Health Maintenance Organization (HMO) - A health insurer or provider that offers

comprehensive services on a pre-paid basis. The HMO contracts or directly employs

physicians to serve as its network. Physicians are paid a salary, reduced fees or a capitated

rate for services. Patient choice is limited to contracted physicians to a varying degree

depending on the type of organization.

Managed care - Any system of health service payment or delivery arrangements in which the

health plan or provider attempts to control or coordinate health service use to contain

health expenditures, improve quality or both. Arrangements often involved a defined

delivery system of providers having some form of contractual relationship with the plan.

Medicaid/Medi-Cal - Federal/California state health insurance system that provides coverage for

those unable to afford private health insurance based upon income criteria.

Medicare - Federal/state health insurance for qualified disabled persons and people over 65

years of age. Medicare Part A covers hospitalization and is mandatory. Medicare Part B

covers outpatient services and is optional.

Multiskilling/Crosstraining - Multiskilling is sometimes referred to as "crosstraining."

Multiskilled workers perform multiple tasks or duties, often with additional training or skill

development. People in both clinical and clerical positions in heath care can be multiskilled.

225




226 On-the-job training (OJT) - OJT refers to the training workers receive on the job. This training

can consist of general orientation or department specific training.

Providers - Those institutions and individual practitioners who provide health care services

(for example, hospitals, skilled nursing facilities, physicians, etc.).

Restructuring/Reengineering - Reengineering is sometimes referred to as restructuring.

Reengineering is the process of evaluating the way jobs and patient care are structured. Job

duties, the level of responsibility that workers have in their jobs, and the number of people

that they interact with may change as the result of reengineering.

Rural/Urban - This report does not use a strict definition for rural and urban areas defined by

metropolitan statistical areas with specific population numbers. Instead, these terms are

used generally to describe areas that are more or less populated, with more or less business

and industry.

Sector - This report uses the term sector to denote industries such as health care or education

as well as broad societal areas such as labor or work.

Setting - This report uses setting to denote different settings within the health care sector,

such as hospitals, long-term care or home health.


CALIFORNIA COUNTY CONSORTIUMS

BAY AREA

AlamedaContra CostaMarinNapaSan FranciscoSan MateoSanta ClaraSolanoSonomaSanta Cruz

GOLDEN SIERRA

AlpineEl DoradoNevadaPlacerSacramentoSierraYolo

MOTHERLODE

AmadorCalaverasMariposaSan JoaquinStanislausTuolumne

INLAND EMPIRE

InyoMonoRiversideSan Bernardino

ORANGE

Orange

227



A P P E N D I X C

CENTRAL COAST

MontereySan BenitoSan Luis ObispoSanta BarbaraVentura

NORTH COUNTIES

Butte ColusaDel NorteGlennHumboldtLakeLassenMendocinoModocPlumasShastaSiskiyouSutterTehamaTrinityYuba

SOUTH VALLEY

MercedFresnoKernKingsMaderaTulare

LOS ANGELES

Los Angeles

SAN DIEGO

ImperialSan Diego


228


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACRUZ

SANMATEO

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS18

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

SAN FRANCISCO

SANTACLARA

ALAMEDA

CONTRACOSTA

Bay Area

Central Coast

Golden Sierra

Inland Empire

Los Angeles

Motherlode

North Counties

Orange

San Diego

South Valley

E X H I B I T C1: California County Consortium Map

DISTRIBUTION OF SELECTED ALLIED HEALTH CARE OCCUPATIONS ANDPROFESSIONS BY CALIFORNIA COUNTY CONSORTIUMS

229



A P P E N D I X D

*Source: State of CA, Department of Finance, Historical City/County Population Estimates, with 1990 Census Counts-1994 Estimates.

**Source: Employment Development Department, Occupational Employment Projections 1992-1994.

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL

California Population

Physical Therapists

COUNTY CONSORTIUM

COUNTY CONSORTIUM

3.1%

20.8%

24.6%

5.3% 5.1%3.3%

0.5%

7.2%4.8% 5.4% 5.2%

29.3%30.1%

8.1%

11.2%9.2%

6.1%

8.8% 9.5%

3.0%

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Physical TherapistsAssistants & Aides

3.1%

20.8%22.4%

5.3% 5.4%3.3%

0.5%

7.2%5.5% 5.4% 5.1%

29.3%

32.3%

8.1%10.6% 9.2%

5.7%

8.8% 8.9%

3.6%

NorthCounties

Bay Area GoldenSierra

Motherlode SouthValley

CentralCoast

LA County Orange InlandEmpire

San Diego

NorthCounties



CentralCoast


San Diego

E X H I B I T D1: Distribution of Physical Therapists Across California County ConsortiumsCalifornia Population* (1994) vs. Physical Therapists, ** (1992–1994)Total Physical Therapists in California = 9,995

E X H I B I T D2: Distribution of Physical Therapists Assistants & Aides Across California County ConsortiumsCalifornia Population* (1994) vs. Physical Therapists Assistants & Aides, ** (1992–1994)Total PT Assistants & Aides in California = 8,830


230




35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Clinical LaboratoryTechnologists

COUNTY CONSORTIUM

COUNTY CONSORTIUM

40%

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Clinical LaboratoryAssistants

NorthCounties



CentralCoast


San Diego

NorthCounties



CentralCoast


San Diego

3.1% 2.2%

20.8%23.3%

5.3% 5.3%3.3%

0.1%

7.2%4.3% 5.4% 4.0%

29.3%

33.3%

8.1%9.7% 9.2%

7.2%

8.8% 10.7%

8.8% 10.5%9.2%

6.0%8.1%

10.9%

29.3%

34.2%

5.4% 3.3%7.2%

2.8%3.3%

0.2%

5.3% 5.9%

20.8%

24.2%

3.1% 2.1%

E X H I B I T D3: Distribution of Medical and Clinical Laboratory Technologists Across California County Consortiums California Population* (1994) vs. Clinical Laboratory Technologists, ** (1992–1994)Total Clinical Laboratory Technologists in California = 17,050

E X H I B I T D4: Distribution of Medical and Clinical Laboratory Assistants Across California County Consortiums California Population* (1994) vs. Clinical Laboratory Assistants, ** (1992–1994)Total Clinical Laboratory Assistants in California = 10,060

231





40%

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


RadiologicTechnologists,Diagnostic

COUNTY CONSORTIUM

COUNTY CONSORTIUM

40%

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Medical RecordsTechnicians

NorthCounties



CentralCoast


San Diego

NorthCounties



CentralCoast


San Diego

3.1%3.7%

20.8% 18.9%

5.3% 3.7%3.3%

0.4%

7.2%4.6% 5.4% 4.7%

29.3%

38.0%

8.1% 9.0% 9.2%

6.8%

8.8% 10.2%

8.8% 9.5%9.2% 8.5%8.1% 7.6%

29.3%

36.2%

5.4% 5.2%7.2%

6.2%3.3%

0.0%

5.3% 3.7%

20.8%20.3%

3.1% 2.7%

E X H I B I T D5: Distribution of Radiologic Technologists, Diagnostic Across California County Consortiums California Population* (1994) vs. Radiologic Technologists, ** (1992–1994)Total Radiologic Technologists in California = 11,535

E X H I B I T D6: Distribution of Medical Records Technicians Across California County Consortiums California Population* (1994) vs. Medical Records Technicians, ** (1992–1994)Total Medical Records Technicians in California = 6,955


232




35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Nurse Aides,Orderlies,Attendants

COUNTY CONSORTIUM

COUNTY CONSORTIUM

35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Home Health CareWorkers

NorthCounties



CentralCoast


San Diego

NorthCounties



CentralCoast


San Diego

3.1% 3.8%

20.8%23.7%

5.3% 5.4%

3.3%0.4%

7.2% 6.4% 5.4% 5.0%

29.3%31.8%

8.1%6.6%

9.2%

7.1%8.8%

9.7%

8.8%

13.1%

9.2%7.1%8.1%

11.8%

29.3%

14.9%

5.4% 6.7%7.2%8.0%

3.3%0.3 %

5.3% 4.9%

20.8%

28.6%

3.1%4.5%

E X H I B I T D7: Distribution of Nursing Aides/Orderlies/Attendants (UAP) Across California County Consortiums California Population* (1994) vs. Nursing Aides/Orderlies/Attendants, ** (1992–1994)Total Clinical Laboratory Technologists in California = 17,050

E X H I B I T D8: Distribution of Home Health Care Workers Across California County Consortiums California Population* (1994) vs. Home Health Care Workers, ** (1992–1994)Total Home Health Care Workers in California = 13,650

233





35%

30%

25%

20%

15%

10%

5%

0%

PE

RC

EN

T O

F TO

TAL


Medical Assistants

COUNTY CONSORTIUM

NorthCounties



CentralCoast


San Diego

3.1% 3.1%

20.8%

24.5%

5.3% 6.0%

3.3%0.3%

7.2% 6.4% 5.4% 5.6%

29.3%27.0%

8.1%10.5% 9.2%

7.9% 8.8% 8.8%

E X H I B I T D9: Distribution of Medical Assistants Across California County Consortiums California Population* (1994) vs. Medical Assistants, ** (1992–1994)Total Medical Assistants in California = 27,715


234

GENDER AND RACE/ETHNICITY OF SELECTED ALLIED HEALTH CARE OCCUPATIONSAND PROFESSIONS


A P P E N D I X E

60%

50%

40%

30%

20%

10%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

TOTAL: 25.9%

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Male Female

12.4%

TOTAL: 57.1%

28.9%

28.2%

TOTAL: 7.1%

TOTAL: 0.6%3.6%

0.3%0.3%

TOTAL: 9.2%

4.7%4.5%

3.5%13.5%

Hispanic White Black American Indian/Eskimo/Aleut

Asian/ Pacific Islander

PE

RC

EN

TAG

E

Source: U.S.Census Bureau, 1990.

Female

Male

Female,All Races

51%N=3,886

Male,All Races

49%N=3,682

40%

35%

30%

25%

20%

15%

10%

5%

0%

5.4% 4.7%

0.2%

3.3%

0.2%

7.1% 5.2%

0.3%

5.6%

0.2%

37.6%

30.3%

E X H I B I T E1: 1990 California Population by Race/Ethnicity

E X H I B I T E2: Respiratory Therapists by Gender and Race in CaliforniaCensus Data, 1990Total Number of Respiratory Therapists: 7,568

235



Male Female

Male Female

70%

60%

50%

40%

30%

20%

10%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Female,All Races

89%N=3,355

Male,All Races

11%N=410

Female,All Races

69%N=8,877

Male,All Races

31%N=3,900

5.4%2.1% 0.2%

4.0% 0.1%

57.6%

2.1% 1.2% 0.2%3.2%

0.0%

23.9%

4.4% 2.2% 0.3%

11.9%

0.0% 2.7% 0.5% 0.0% 1.5% 0.0%

70.3%

6.2%

80%

70%

60%

50%

40%

30%

20%

10%

0%

E X H I B I T E3: Occupational Therapists by Gender and Race in CaliforniaCensus Data, 1990Total Number of Occupational Therapists: 3,765

E X H I B I T E4: Physical Therapists by Gender and Race in CaliforniaCensus Data, 1990Total Number of Physical Therapists: 12,777


236


Male Female

Male Female

70%

60%

50%

40%

30%

20%

10%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Female,All Races

90%N=5,593

Male,All Races

10%N=653

3.1% 1.2% 0.2% 3.9% 0.2%

80.9%

0.3% 0.4% 0.0% 0.3% 0.0%

9.4%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Female,All Races

73%N=5,794

Male,All Races

27%N=2,148

7.2%3.5%

0.7% 3.9%

0.0%

57.7%

3.2% 3.5%0.0% 1.4% 0.2%

18.8%

E X H I B I T E5: Speech Therapists by Gender and Race in CaliforniaCensus Data, 1990Total Number of Speech Therapists: 6,246

E X H I B I T E6: Therapists n.e.c by Gender and Race in CaliforniaCensus Data, 1990Total Number of Therapists n.e.c: 7,942

237



Male Female

Male Female

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Female,All Races

97.2%N=7,655

5.8%

1.4% 0.2%

8.8%

0.0%

80.9%

0.5% 0.2% 0.1% 0.2% 0.0%1.9%

Male,All Races

2.8%N=223

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Female,All Races

66.1%N=22,179

Male,All Races

33.9%N=11,399

4.7%

0.2%

16.9%

0.1%

38.3%

5.9%4%2% 0.0%

9%

0.0%

19%

E X H I B I T E7: Clinical Laboratory Technologists and Technicians by Genderand Race in CaliforniaCensus Data, 1990Total Number of Clinical Laboratory Technologists and Technicians: 33,578

E X H I B I T E8: Dental Hygenists by Gender and Race in CaliforniaCensus Data, 1990Total Number of Dental Hygenists: 33,578


238


Male Female

Male Female

60%

50%

40%

30%

20%

10%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Male,All Races

4%N=934

Female,All Races

96%N=23,710

22.9%

4.4% 0.7%

9.1%

0.2%

58.9%

Male,All Races

15%N=978

Female,All Races

85%N=5,451

14.4%9.3%

0.9%

11.0%

0.0%

49.2%

2.3% 2.8%0.0%

4.5%0.0%

5.5%

70%

60%

50%

40%

30%

20%

10%

0%1.3% 0.2% 0.0% 1.2% 0.0%1.0%

E X H I B I T E9: Dental Assistants by Gender and Race in CaliforniaCensus Data, 1990Total Number of Dental Assistants: 24,644

E X H I B I T E10: Health Records Technologists and Technicians by Genderand Race in CaliforniaCensus Data, 1990Total Number of Health Records Technologists and Technicians: 6,429

239



Male Female

Male Female

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Male,All Races

42%N=5,887

Female,All Races

58%N=8,231

6.9% 3.9% 0.6%

4.2% 0.0%

42.9%

10.4%

3.8%0.2%

5.1%

0.1%

22.1%

Male,All Races

30%N=14,742Female,

All Races70%

N=34,682

14.8%

4.7%

0.4%

6.2%

0.1%

44.0%

5.6% 2.3%0.2%

3.4%

0.1%

18.1%

50%

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

E X H I B I T E11: Radiologic Technicians by Gender and Race in CaliforniaCensus Data, 1990Total Number of Radiologic Technicians: 14,118

E X H I B I T E12: Health Technologists and Technicians, n.e.c. by Genderand Race in CaliforniaCensus Data, 1990Total Number of Health Technologists and Technicians: 49,424


240


Male Female

Male Female

45%

40%

35%

30%

25%

20%

15%

10%

5%

0%

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Hispan

icW

hite

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Islan

der

Other R

ace

Hispan

ic

Whit

e

Black

America

n Ind

ian/

Eskim

o/Aleu

t

Asian/P

acific

Island

er

Other R

ace

Male,All Races

17%N=27,758

Female,All Races

83%N=132,240

21.5%

14.5%

1.1%

9.7%

0.2%

35.6%

4.3%2.7%

0.2%2.2%

0.0%

7.9%

Male, All Races25%

N=4,576

Female, All Races75%

N=14,010

15.3%

6.8%

0.5%

10.4%

0.1%

42.2%

6.2% 2.7%0.2%

4.3%

0.0%

11.3%

40%

35%

30%

25%

20%

15%

10%

5%

0%

E X H I B I T E13: Nursing Aides, Orderlies and Attendants by Genderand Race in CaliforniaCensus Data, 1990Total Number of Nursing Aides, Orderlies and Attendants: 159,998

E X H I B I T E14: Health Aides (except nursing) by Gender and Race in CaliforniaCensus Data, 1990Total Number of Health Aides: 18,586

WAGES FOR SELECTED ALLIED AND AUXILIARY HEALTH CARE OCCUPATIONS ANDPROFESSIONS BY CALIFORNIA COUNTIES

241



A P P E N D I X F

SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$8.78

$9.14

$9.32

$9.51

$10.27

$11.01

Source: Employment Development Department/Labor Market Information Division,

1996 4th Quarter Occupational Employment and Wage Data,

Occupational Employment Statistics (OES) Survey Results.

E X H I B I T F1: Weighted Average of Housekeeping Hourly Wages in California by County, 1996


242


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$7.50 to $8.49

$8.50 to $9.49

$9.50 to $10.49

$10.50 to $11.49

$11.50 to $12.49

Source: Employment Development Department/Labor Market Information Division, 1996 4th Quarter Occupational

Employment and Wage Data, Occupational Employment Statistics (OES) Survey Results.

E X H I B I T F2: Median Hourly Wages for Medical Assisants in California by County, 1996

243



SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$5.50 to $6.49

$6.50 to $7.49

$7.50 to $8.49

$8.50 to $9.49

$9.50 to $10.49

Source: Employment Development Department/Labor Market Information Division, 1996 4th Quarter Occupational

Employment and Wage Data, Occupational Employment Statistics (OES) Survey Results.

E X H I B I T F3: Median Hourly Wages for Nursing Aides, Orderlies and Attendants in California by County, 1996


244


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$7.00 to $8.49

$8.50 to $9.99

$10.00 to $12.49

$12.50 to $19.49

Data Outside Range

Source: Office of Statewide Health Planning and Development (OSHPD): Hospital Annual Disclosure Reports, 1995-1996.

Notes: Nursing Aides and Orderlies defined as OSHPD Employee Classification Code.04.

Mean Hourly Wages reported in OSHPD Cost Center: Total Ancillary Services.

E X H I B I T F4: Median Hourly Wages for Nursing Aides, Orderlies in California Hospitals by County, 1996

245



SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$6.25 to $7.49

$7.50 to $8.49

$8.50 to $10.49

$10.50 to $12.49

$12.50 to $14.50


Notes: Environmental and Food Service Personnel defined as OSHPD Employee Classification Code .06.

Mean Hourly Wages reported in OSHPD Cost Center: Total General Services.

E X H I B I T F5: Median Hourly Wages for Environmental and Food Service Personnel in California Hospitals by County, 1996


246


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$13.00 to $16.49

$16.50 to $18.49

$18.50 to $20.49

$20.50 to $22.49

$22.50 to $24.50


Notes: Technicians and Specialists defined as OSHPD Employee Classification Code .01.

Mean Hourly Wages reported in OSHPD Cost Center: Total Ancillary Services.

E X H I B I T F6: Median Hourly Wages for Technicians and Specialists in California Hospitals by County, 1996

247



��

SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$8.50 to $10.49

$10.50 to $13.49

$13.50 to $15.49

$15.50 to $17.49

$17.50 to $20.50

Source: Office of Statwide Health Planning and Development (OSHPD): Hospital Annual Disclosure Reports, 1995-1996.

Notes: Technicians and Specialists defined as OSHPD Employee Classification Code .01.

Mean Hourly Wages reported in OSHPD Cost Center: Medical Records–Administrative Services.

E X H I B I T F7: Median Hourly Wages for Medical Records — Technicians and Specialists in California Hospitals by County, 1996


248


SAN BERNARDINO

RIVERSIDE

INYO

KERN

LOS ANGELES

ORANGE

SAN DIEGOIMPERIAL

VENTURA

SANTA BARBARA

SAN LUIS OBISPO

TULARE

KINGS

MONTEREY

FRESNO

MADERA

MARIPOSA

MERCED

SANBENITO

SANTACLARA

SANTACRUZ

SANMATEO

SAN FRANCISCO

CONTRACOSTA

ALAMEDA

SOLANO

MARIN

SONOMA NAPA

SANJOAQUIN

STANISLAUS

TUOLUMNE

ALPINE

MONO

YOLO

AMADOR

EL DORADO

PLACERCOLUSALAKE

MENDOCINO

GLENN BUTTE

TEHAMAPLUMAS

SIERRA

LASSENSHASTATRINITY

HUMBOLDT

SISKIYOU MODOC

DELNORTE

NEVADAYUBA

SUTTER

SACRAMENTO

CALAVERAS

Data Not Available

$6.25 to $7.49

$7.50 to $9.49

$9.50 to $11.49

$11.50 to $13.49

$13.50 to $15.25

Source: Office of Statwide Health Planning and Development (OSHPD): Hospital Annual Disclosure Reports, 1995-1996.

Notes: Clerical Personnel defined as OSHPD Employee Classification Code .05.

Mean Hourly Wages reported in OSHPD Cost Center: Medical Records — Administrative Services.

E X H I B I T F8: Median Hourly Wages for Medical — Clerical Personnel in California Hospitals by County, 1996

1. O’Neil EH, and the Pew Health Professions Commission. Recreating Health ProfessionalPractice for a New Century. San Francisco, CA: Pew Health Professions Commission,December 1998, p.6.

2. Office of Statewide Health Planning and Development. Aggregate Hospital Financial DataSummary. Sacramento, CA: Office of Statewide Health Planning and Development,1997, p. 1.

3. O’Neil EH, and the Pew Health Professions Commission. Recreating Health ProfessionalPractice for a New Century. San Francisco, CA: Pew Health Professions Commission,December 1998, p. 7.

4. Lamphere J, Brangan N, Bee S, Semansky R, and the American Association ofRetired Persons Public Policy Institute. Reforming the Health Care System: State Profiles 1998.Washington, DC: American Association of Retired Persons Public Policy Institute.1998, p. 20.

5. Center for Studying Health System Change. The Community Snapshots Project: Capturing HealthSystem Change. Seattle, WA: Center for Studying Health System Change, 1995, p. 1.

6. Cerne F. San Diego: As a Market Matures, Networks Feel Growing Pains. Hospitals &Health Networks. 1995:69(2), p. 58.

7. Ibid.

8. Center for Studying Health System Change. The Community Snapshots Project: Capturing HealthSystem Change. Seattle, WA: Center for Studying Health System Change, 1995, p. 1.

9. Miller RH, Lipton HL, Duke KS and Sierra Health Foundation. Health System Change inthe Greater Sacramento Area. Sacramento, CA: Sierra Health Foundation, 1997, p. 7-8.

10. Ibid.

11. Brenden J, Hamer RL and Interstudy Publications. The Interstudy HMO Trend Report1987-97. Bloomington, MN: Interstudy Publications, August 1998, p. 188-317.

12. Center for the Health Professions. Future Directions for Graduate Medical Education in the CentralSan Joaquin Valley. San Francisco, CA: Center for the Health Professions, 1996, p. 19-23.

13. California Healthline. Elements of Reform - Rural Care: Making Strides inUnderserved Areas. California HealthCare Foundation by National Group, Inc. Copyright 1994National Group, Inc. March 25, 1994.

14. Hurly J. Health Net Decision Targets Seniors. San Luis Obispo County Telegram-Tribune.Copyright 1998 San Luis Obispo County Telegram-Tribune. June 25, 1998.

15. Appleby J. Another Blow for Medicare HMOs: Blue Shield To Stop Signing Up NewMembers in Northern California, Although It Will Still Service Current Customers.Contra Costa Times. Copyright 1998 Contra Costa Times. August 5, 1998.

249



C I T A T I O N S


250 16. Hurly J. Health Net Decision Targets Seniors. San Luis Obispo County Telegram-Tribune.Copyright 1998 San Luis Obispo County Telegram-Tribune. June 25, 1998.

17. Appleby J. Another Blow for Medicare HMOs: Blue Shield To Stop Signing Up NewMembers in Northern California, Although It Will Still Service Current Customers.Contra Costa Times. Copyright 1998 Contra Costa Times. August 5, 1998.

18. Bloomberg News. Foundation Health’s Profit Falls 43% on Increased Costs. The LosAngeles Times. Copyright 1998 Los Angeles Times. August 12, 1998.

19. California Healthline. Blue Cross: Receives Special Healthy Families Status in ButteCounty. California HealthCare Foundation by National Group, Inc. Copyright 1998 NationalGroup, Inc. June 2, 1998.

20. Franklin A. Doing It All in the Public Eye: A Comparative Analysis of CaliforniaDistrict Hospital Affiliations. Journal of Health Care Finance. Winter 1998: 24(2), p. 48-55.

21. HMO Statewide Propac, Healthcare Databank, Inc. P.O. Box 1576, Santa Rosa, CA95476. 1989.

22. California Association of Health Plans. Retrieved from: http://www.calhealthplans.com.

23. Ciba-Geigy, 1996 Trends and Forecasts.

24. Handy CB. The Future of Work: A Guide to a Changing Society. New York, NY: B. Blackwell, 1994.

25. Flower J. Job Shift: A (Scary) Conversation with William Bridges and NeilsonBuchanan. Health care Forum Journal. Jan/Feb 1997:40(1), p. 459-468.

26. Handy CB. The Age of Paradox. Boston, MA: Harvard Business School Press, 1994.

27. Mitchell S. How to Talk to Young Adults. American Demographics. April 1993.

28. Bureau of Labor Statistics. Employment by Major Occupational Group, 1986, 1996, andProjected 2006. Retrieved from: http://stats.bls.gov/news.release/ecopro.table3.html.

29. Flower J. Job Shift: A (Scary) Conversation with William Bridges and NeilsonBuchanan. Health care Forum Journal. Jan/Feb 1997:40(1), p. 459-468.

30. U.S. Bureau of the Census - Population Division. U.S. Population Estimates by Age,Sex, Race, and Hispanic Origin: 1980 to 1997 (With Extension to May 1, 1998).Retrieved from: http://www.census.gov/population/www/estimates/nation3.html.

31. Siegel J, and the Administration on Aging, U.S. Department of Health and HumanServices. Aging into the 21st Century. Washington, DC: National Aging InformationCenter, May 31, 1996.

32. Dey AN. Characteristics of Elderly Nursing Home Residents: Data from the 1995National Nursing Home Survey. Advance Data from Vital and Health Statistics. 1979: 289.


33. Siegel J, and the Administration on Aging, U.S. Department of Health and HumanServices. Aging into the 21st Century. Washington, DC: National Aging InformationCenter, May 31, 1996.

34. Rivlin AM, Weiner JM, Hanley R, Spence D. Caring for the Disabled Elderly: Who Will Pay?Washington, DC: The Brookings Institution, 1988, p. 30-50, Table 2-4.

35. Bureau of Labor Statistics. Civilian Labor Force by Sex, Age, Race and HispanicOrigin, 1986, 1996, and Projected 2006.Retrieved from: http://stats.bls.gov/news.release/ecopro.table1.html.

36. Stoneman B. Beyond Rocking the Ages: An Interview with J. Walker Smith. AmericanDemographics. May 1998.

37. U.S. Bureau of the Census — Population Division. U.S. Population Estimates by Age,Sex, Race, and Hispanic Origin: 1980 to 1997 (With Extension to May 1, 1998).Retrieved from: http://www.census.gov/population/www/estimates/nation3.html.

38. Nickens HW, Cohen JJ. Policy Perspective: On Affirmative Action. Journal of theAmerican Medical Association. February 21, 1996: 275(7), p. 572.

39. Drake MV and Lowenstein DH. The Role of Diversity in the Health Care Needs ofCalifornia. West Journal of Medicine. May 1998:168(5), p. 348-54.

40. Ibid.

41. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, BindmanAB. The Role of Black and Hispanic Physicians in Providing Health Care forUnderserved Populations. The New England Journal of Medicine. May 16, 1996:334(20), p. 1305-1310.

42. Nickens HW, Cohen JJ. Policy Perspective: On Affirmative Action. Journal of theAmerican Medical Association. February 21, 1996: 275(7), p. 572.

43. Gupta GC and Konrad TR. Allied Health Education in Rural Health ProfessionalShortage Areas of the United States. Journal of the American Medical Association. September1992:268(9), p. 1127-30.

44. Ibid.

45. Gupta GC and Konrad TR. Allied Health Education in Rural Health ProfessionalShortage Areas of the United States. Journal of the American Medical Association. September1992:268(9), p. 1127-30.

46. Ibid.

47. U.S. Department of Health and Human Services. Minorities and Women in the Health Fields.Washington, DC: U.S. Department of Health and Human Services, 1994.

251




252 48. Berkowitz G, Grumbach K and the Institute for Health Policy Studies incollaboration with Center for the Health Professions. Affirmative Action and Health Status: AReview of the Literature. San Francisco, CA: Institute for Health Policy Studies and Centerfor the Health Professions, December 1998.

49. Finocchio LJ, Dower CM, Blick NT, Gragnola CM and the Taskforce on Health CareWorkforce Regulation. Strengthening Consumer Protection: Priorities for Health Care WorkforceRegulation. San Francisco, CA: Pew Health Professions Commission, October 1998.

50. Ibid.

51. Coffman J, and the Center for the Health Professions. Health Professions Education MasterPlan for the Central San Joaquin Valley Preliminary Report. San Francisco, CA: Center for theHealth Professions, 1996, p. 47.

52. Ibid.

53. Coffman J, and the Center for the Health Professions. Health Professions Education MasterPlan for the Central San Joaquin Valley Preliminary Report. San Francisco, CA: Center for theHealth Professions, 1996, p. 47.

54. California Healthline. Health Premiums: Californians Face Big Hikes. CaliforniaHealthCare Foundation by National Group, Inc. Copyright 1998 National Group, Inc.,November 2, 1998.

55. McConnell S. The Role of Computers in Reshaping the Work Force. Monthly LaborReview. August 1996:119(8), p. 3-5.

56. Torres RE. The Impact of Technological Change on Clinical Laboratory andRadiology Manpower. Human Systems Management. 1988: 7, p. 367-374.

57. Healthcare Infirmities, December 1995, p. 15.

58. California Healthline. Telemedicine: Five Medical Organizations Awarded Grants.California HealthCare Foundation by National Group, Inc. Copyright 1998 National Group, Inc.July 9, 1998.

59. National Center for Research Resources. 6705 Rockledge Drive, MSC 7965, Bethesda,MD 20892-7965. (301) 435-0755. Retrieved from: http://www.ncrr.nih.gov/biotech.htm.

60. Ruzek J, and the Center for the Health Professions. Trends in U.S. Funding for BiomedicalResearch. San Francisco, CA: Center for the Health Professions, May 1996, p. 3-4.

61. Torres RE. The Impact of Technological Change on Clinical Laboratory andRadiology Manpower. Human Systems Management. 1988: 7, p. 367-374.

62. Philips K. The Politics of Rich and Poor. New York: Harper Collins, 1991, p. 14.

63. Hausman, T. How Californians get well. (survey by Healthdemographics on medicalservices utilized by state’s residents). Wall Street Journal. Wed. March 18, 1998:CA4(W)pages., col2.


64. Hausman, T. California’s biggest metropolitan areas exceed the national mean.(survey by Healthdemographics). Wall Street Journal. Wed. March 18, 1998.

65. Age and State-Specific Prevalence Estimates of Insured and Uninsured Persons-United States, 1995–1996. Morbidity and Mortality Weekly Report. July 3, 1998: pp529-532.

66. Schauffler JJ, McMenamin S, Cubanski J, Brown ER, Rice T. The State Of Health Insurancein California, 1998. Berkeley, CA: Center for Health and Public Policy Studies and LosAngeles, CA: Center for Health Policy Research, January 1999.

67. Ibid.

68. Himmelstein DU, Lewontin JP, Woolhandler S. Medical Care Employment in theUnited States, 1968 to 1993: The Importance of Health Sector Jobs for AfricanAmericans and Women. American Journal of Public Health. April 1996:86, p. 525-528.

69. The 1998 California Work and Health Survey. Work and Health Program, Institutefor Health Policy Studies. University of California, San Francisco.

70. Gottschalk P. Trends in Wages and Health Insurance Status of Less Educated Workers: A Report on theFuture of Low Wage Labor Markets. Prepared for the Henry J. Kaiser Family Foundation.April 1998.

71. Ibid.

72. DeParle J. Welfare Rolls Show Growing Racial and Urban Imbalance. The New YorkTimes. Copyright 1998 The New York Times Company. July 27, 1998.

73. Office of Statewide Health Planning and Development.Retrieved from: http://www.oshpd.cahwnet.gov/.

74. Office of Statewide Health Planning and Development. Hospital Quarterly Data Trends.Sacramento, CA: Office of Statewide Health Planning and Development, March1998, Volume 1(3).

75. Melnick G, Zwanziger J. Competition Lowers Cost at California Hospitals. Hospitals.January 5, 1989, p. 56-58.

76. Sofaer S. Restrictive Reimbursement Policies and Uncompensated Care inCalifornia Hospitals, 1981-1986. Hospital & Health Services Administration. Summer 1990:35(2), p. 189-206.

77. Ibid.

78. The Joint Commission on Accreditation of Healthcare Organizations. Retrieved from: http://www.jcaho.org.

79. Anderson GF, Kohn LT. Employment Trends in Hospitals, 1981-1993. Inquiry. Spring1996: 33, p. 79-84.

80. Havlicek PL, and the American Medical Association. AMA Medical Groups Practicesin the U.S.: A Survey of Practice Characteristics 1999 Edition. Chicago, IL:American Medical Association, 1999.

253




254 81. Grumbach K, Coffman J, Blick N, O’Neil E and Vranizan K. Independent PracticeAssociation Physician Groups in California. Health Affairs. May/June 1998, p.227–237.

82. Robinson JC. Financial Capital and Intellectual Capital in Physician PracticeManagement. Health Affairs. July-August 1998: 17(4), p. 53-74.

83. Havlicek PL, and the American Medical Association. AMA Medical Groups in theU.S.: A Survey of Practice Characteristics 1996 Edition. Chicago, IL: AmericanMedical Association, 1996. p.36.

84. McGuire JP. Ambulatory Care Services Continue to Grow. HealthCare FinancialManagement. November 1994: 48(11), p. 10.

85. Allen DW, Weber, D. Ambulatory Care Planning for a Hospital. Health Care StrategicManagement. February 1995: 13(2), p. 17-20.

86. Averill RF, Goldfield NI, Wynn ME, McGuire TE, et al. Design of a ProspectivePayment Patient Classification System for Ambulatory Care. Health Care Financing Review.Fall 1993: 15(1), p. 71-100.

87. Office of Statewide Health Planning and Development. Licensed Services and Utilization Dataof Licensed Home Health Agencies, Report Period: January 1,1995 to December 31, 1995. Sacramento,CA: Office of Statewide Health Planning and Development, 1995, p. D2.

88. Freeman L. Home-Sweet-Home Health Care: Home Health Services Growth. MonthlyLabor Review. March 1995: 118(3), p. 4.



91. O’Neil E, Coffman J. Strategies for the Future of Nursing: Changing Roles, Responsibilities and EmploymentPatterns of Registered Nurses. San Francisco, CA: Jossey-Bass Publishers, 1998, p. 160.


93. Pace K. The Balanced Budget Act: Effects in Home Care Beneficiaries and Providers.Caring. August 1998, p. 11.

94. Ibid.





98. Dombi WA, St. Pierre M. Interim Payment System and Risk Management. Caring.February 17, 1998: 2, p. 38-40,42.

99. Industry Leadership Forum Recommends Strategies for the Future. Caring, 1995,14(10), 40-58.

100. Office of Statewide Health Planning and Development. Licensed Services and Utilization Dataof Licensed Home Health Agencies, Report Period: January 1,1995 to December 31, 1995. Sacramento,CA: Office of Statewide Health Planning and Development, 1995, p. 1.


102. Snow C. Home Health Heats Up: Survey Finds Massive Change at Industry’sDoor. Modern HealthCare. August 18, 1997, p. 28.

103. Office of Statewide Health Planning and Development. Annual Utilization Report of Long-Term Care Facilities: Licensed Services and Utilization Profiles: Report Period January 1, 1995 throughDecember 31, 1995. Sacramento, CA: Office of Statewide Health Planning andDevelopment, January 1997.

104. Ibid.

105. Harrington C, Swan JH. 1995 State Data Book on Long Tem Care: Program and Market Characteristics.San Francisco, CA: Department of Social & Behavioral Services, and Wichita, Kansas:Department of Health Services Organization and Policy, November 1996, p.31-33.

106. Harrington C, Carrillo H, Thollaug S, Summers P. Nursing Facilities, Staffing, Residents, andFacility Deficiencies, 1991-1996. San Francisco, CA: Department of Social & BehavioralSciences, January 1998.

107. HCIA and Arthur Andersen. 1994 Guide to the Nursing Home Industry. Baltimore: HCIA,Inc. and Arthur Andersen & Company, 1994.


109. Sward S. Clinton Calls for Reform of Nursing Home Industry: Surprise Visits,Higher Penalties Ordered. San Francisco Chronicle. Copyright 1998 San FranciscoChronicle. July 22, 1998.

110. Harrington C, Zimmerman D, Karon S, Robinson J, Beutel P. Nursing Home Staffing andIts Relationship to Quality. San Francisco, CA: Department of Social & BehavioralSciences, and Madison, WI: Center for Health Systems Research and Analysis,November 1997, p.1.

111. Harrington C, Zimmerman D, Karon S, Robinson J, Beutel P. Nursing Home Staffing andits Relationship to Quality. Department of Social & Behavioral Sciences, University ofCalifornia, San Francisco. Center for Health Systems Research and Analysis,University of Wisconsin. November 1997. p.1.


255




256 113. American Association of Retired Persons and the Administration on Aging. A Profile ofOlder Americans. Washington D.C.: American Association of Retired Persons and theAdministration on Aging, U.S. Department of Health and Human Services, 1997Retrieved from: http://pr.aoa.dhhs.gov/aoa/states/profile/#living.

114. Murtaugh CM, Kemper P, Spillman BC. The Risk of Nursing Home Use Later inLife. Medical Care. 1990: 28(10), p. 952-962.


116. U.S. Department of Health and Human Services, Health Care FinancingAdministration. Medicare and Medicaid Requirements for long-term care Facilities. Final Rule.Federal Register, 1991.

117. Haugh R. Network News. Hospitals & Health Networks. April 5, 1998: 72(7), p. 44.

118. Employment Development Department, Labor Market Information Division, SpecialRun, 1999. Based on industry employment projections. Analysis by the Center for theHealth Professions.

119. Coffman JM, Young JQ, Vranizan K, Blick N, Grumbach K. California Needs BetterMedicine: Physician Supply and Medical Education in California. San Francisco, CA: CaliforniaPrimary Care Consortium and the Center for the Health Professions, May 1997.

120. Current Population Survey, Bureau of Labor Statistics, 1998 annual averages.Estimates for union representation.

121. Fottler MD. The Role and Impact of Multiskilled Health Practitioners in the HealthServices Industry. Hospital & Health Services Administration. Spring 1996: 41(1), p. 55-75.

122. Makely S. Multiskilled Health Care Workers: Issues and Approaches to Crosstraining. IN: Pine RidgePublications, 1998, p. 21.




126. FarWest Laboratory for Educational Research and Development. National Health Care SkillStandards Project. San Francisco, CA: FarWest Laboratory for Educational Research andDevelopment, 1996, p.1-13.

127. Hensley S. Outsourcing Boom. Modern Healthcare. September 1, 1997, p.51-56.

128. Ibid.

129. Ibid.


130. Marriott Management Services. Retrieved from: http://www.marriott.com.

131. Ibid

132. Larson J. Temps. American Demographics. February 1996, p.26-31.

133. Ibid.

134. Ibid

135. RAPID TEMPS Professional Medical Staffing. Retrieved from: http://rapidtemps.com.

136. U.S. Department of Health and Human Services. Report of the National Commission on AlliedHealth. Rockville, MD: U.S. Department of Health and Human Services, Public HealthService, Health Resources and Services Administration, Bureau of Health Professions,Division of Associated, Dental, and Public Health Professions, 1995, p. 65.

137. Medical Group Management Association, California Medical Practice EmployeeSalary Survey. Retrieved from: http://www.mgma.com.

138. Cleeland N. Home-Care Workers’ Vote for Union a Landmark for Labor.The Los Angeles Times. Copyright 1999 Los Angeles Times. February 26, 1999.

139. Greenhouse S. In Biggest Drive Since 1937, Union Gains a Victory. The New York Times.Copyright 1999 The New York Times Company. February 26, 1999.

140. Rauber, Chris. “Labor Pains”. Modern HealthCare, November 9, 1998: 102-106.

141. Kaiser Permanente and Local 399. “Baldwin Park Blitz: Another Step Forward”(videotape). 1998.

142. Rauber, Chris. “Labor Pains”. Modern HealthCare, November 9, 1998: 102-106

143. California School Board Association, California Public Schools. Retrieved from: http://www.calschools.csba.org/.

144. California Department of Education Health Careers Education and California StatePolytechnic University Pomona. Health Careers Related Multi-Cultural Diversity Guide.Sacramento, CA: California Department of Education, 1996.

145. California Department of Education. Career Pathways Report. Sacramento, CA:California Department of Education, 1997, Volume IV, No.20.

146. Ibid.

147. California School Board Association, California Public Schools. Retrieved from: http://www.calschools.csba.org/.

148. California Department of Education. Health Careers Education 2000: A Program Guide.Sacramento, CA: Health Careers Education Program, School-to-Career Unit, 1998.

257




258 149. Arenson K. More Colleges Plunging into Uncharted Waters of Online Courses. The New York Times. Copyright 1998 The New York Times Company. November 2, 1998.

150. Jones D, Ewell P, McGuinness A. The Challenges and Opportunities Facing Higher Education: AnAgenda for Policy Research. San Jose, CA: The National Center for Public Policy andHigher Education, 1998, p. 13.

151. Mathews D. The Transformation of Higher Education through InformationTechnology: Implications for State Higher Education Finance Policy. Educom Review.September/October 1998, p. 51.

152. Nussbaum D. Computer Haves and Have-Nots in the Schools. The New York Times.Copyright 1998 The New York Times Company. October 22, 1998.

153. Edmundson, Mark, Crashing the Academy, New York Times Magazine, April 4, 1999. 9-10.

154. Policy Perspectives, “A Very Public Agenda.” A periodic publication by the Knight HigherEducation Collaborative, September 1998.

155. Leslie LL, Brinkman PT. The Economic Value of Higher Education. New York, NY: AmericanCouncil on Education, Macmillan Publishing Co., 1998, p. 2.

156. RAND/Council for Aid to Education. Breaking the Social Contract: The Fiscal Crisis in HigherEducation. New York, NY: Council for Aid to Education, 1997, p. 4.

157. Ibid.

158. Policy Perspectives, “A Very Public Agenda.” A periodic publication by the Knight HigherEducation Collaborative, September 1998.

159. Gray K, Herr E. B.A. Degrees Should Not Be ‘The Only Way.’ The Chronicle of HigherEducation. May 10, 1996, p. B1-2.

160. Hovey H, and the State Policy Research, Inc. State Spending for Higher Education inthe Next Decade: The Battle to Sustain Current Support. Washington, DC: StatePolicy Research, Inc., 1999, p. 8.

161. Hovey H, and the State Policy Research, Inc. State Spending for Higher Education inthe Next Decade: The Battle to Sustain Current Support. Washington, DC: StatePolicy Research, Inc., 1999, p. 14.

162. Kindy K. College Debt Soars Statewide. Orange County Register. Copyright 1997 OrangeCounty Register. June 24, 1997.

163. Goldstein L, and the Western Association of College and University BusinsessOfficers. Tuition Discounting: 1996 NACUBO Tuition Discounting Survey Results. Anchorage, AL:Western Association of College and University Business Officers, 1997.

164. Doti JL. ‘Discounts’ Make Colleges Murch More Affordable for Low-IncomeStudents. The Chronicle of Higher Education. February 6, 1998, p. B7.

165. Kennedy D. How to Pay for a Good College: The Student Aid Game. The AtlanticMonthly. March 1998, p. 112-116.


166. American Association of State Colleges and Universities. Special Report on Prepaid Tuition Plans.Washington, DC: American Association of State Colleges and Universities, 1997.

167. National Center for Public Policy and Higher Education. Maximizing Effectiveness of the NewFederal Tuition Tax Credits: Assessing Possible State Policy Responses. San Jose, CA: National Centerfor Public Policy and Higher Education, 1998.

168. National Center for Education Statistics, Findings from the Condition of Education1996: Preparation of Work. http://nces.ed.gov.

169. What Work Requires of Schools, The Secretary’s Commission on Achieving Necessary Skills. ETA Dissemination Unit, U.S. Department of Labor. Retrieved from: http://infinia.wpmc.jhu.edu/workreq.html.

170. Learning a Living: A Blueprint for High Performance. The Secretary’s Commissionon Achieving Necessary Skills. ETA Dissemination Unit, U.S. Department of Labor.Retrieved from: http://infinia.wpmc.jhu.edu/workreq.html.

171. Boyett JH, Snyder DP. Twenty-First Century Workplace Trends. On the Horizon: TheStrategic Planning Resource for Education Professionals. March/April 1998: 6(2), p. 6.

172. Sternberg RJ. Successful Intelligence. New York, NY: Simon and Schuster, 1996.

173. Oblinger DG, Verville AL. What Business Wants from Higher Education. Washington, DC:Oryx Press, 1998, p. 73.

174. Bishop J. Occupation-Specific versus General Education and Training. The Annals of theAmerican Academy of Political and Social Science. September 1998: 559, p. 29.

175. American Council on Education. Educating Americans for a World in Flux: Ten Ground Rules forInternationalizing Higher Education. Washington, DC: American Council on Education, 1996, p. 5.

176. Learning a Living: A Blueprint for high Performance. The Secretary’s Commissionon Achieving Necessary Skills. ETA Dissemination Unit, U.S. Department of Labor.Retrieved from: http://infinia.wpmc.jhu.edu/workreq.html.

177. California Department of Education. Retrieved from: http://www.cde.ca.gov/.

178. Ibid.

179. Ibid.

180. EdSource. Retrieved from: http://www.edsource.org/.

181. Ibid.

182. Anderson N. State’s Students Rank Below National Average. The Los Angeles Times.Copyright 1998 Los Angeles Times. July 22, 1998.

183. Colvin RL. State Ranks Near Bottom on Math Skills Test. The Los Angeles Times.Copyright 1997 Los Angeles Times. February 28, 1997.

259




260 184. Anderson N. State’s Students Rank Below National Average. The Los Angeles Times.Copyright 1998 Los Angeles Times. July 22, 1998.

185. Ibid.

186. Sanchez R. U.S. High School Seniors Rank Near Bottom (in Math and Science).The Washington Post. Copyright 1998 Washington Post. February 25, 1998.

187. Shogren E. Clinton to Convene Math, Science Panel. The Los Angeles Times.Copyright 1998 Los Angeles Times. March 8, 1998.

188. Bronner E. U.S. 12-Graders Rank Poorly in Math and Science, Study Says. The NewYork Times. Copyright 1998 The New York Times Company. February 25, 1998.

189. Hiraoka L. The International Test Scores are in...(US Students Do Not Do Well).National Education Association Today. 1998: 16(9). p. 19.

190. Ibid.

191. Hoover K. State Data Hint Smaller Classes are Effective. San Francisco Chronicle.Copyright 1998 San Francisco Chronicle. December 29 1998.

192. EdSource. Retrieved from: http://www.edsource.org/.

193. Corporate Securities, Inc. Corporate Universities Thriving. Newsletter. July-August1997: 1(2), p. 6.

194. Western Association of Schools and Colleges. Accreditation Handbook. Oakland, CA:Western Association of Schools and Colleges, 1988, p. 202.

195. Almanac Issue. Chronicle of Higher Education. August 28, 1998:XLV(1), p. 50.

196. The University of California at San Francisco (UCSF). Retrieved from: http://www.ucsf.edu/.

197. California Postsecondary Education Commission. Student Profiles, 1998. Sacramento,CA: California Postsecondary Education Commission, Meeting of August 23-24,1998, Agenda Item 4.

198. California Postsecondary Education Commission. Student Profiles, 1997. Sacramento,CA: California Postsecondary Education Commission, Meeting of August 24-25,1997, Agenda Item 5.

199. Strosnider K. An Aggressive For-Profit University Challenges Traditional CollegesNationwide. The Chronicle of Higher Education. June 6, 1997, p.A32-A33.

200. National Center for Education Statistics, Digest of Education Statistics, 1997.Retrieved from: http://nces.gov/pubs/digest97/d97t356.html.

201. The Accrediting Commission of Career Schools and Colleges of Technology.Retrieved from: http://www.accsct.org/.

202. Weiss K. Most Cal State Freshmen Not Math Ready. Los Angeles Times. Copyright 1998Los Angeles Times. March 18, 1998: A16.


203. National Center for Educational Statistics, ED Pubs. Retrieved from: http://nces.ed.gov.

204. The Institute for Higher Education Policy. College Remediation: What It Is, What It Costs, What’ s atStake. Washington, DC: The Institute for Higher Education Policy, December 1998, p. 4.

205. Inkenberry S, Stix N. Q: Should Colleges Offer Remedial-Education Programs forStudents? Insight on the News. June 29, 1998, p.24.


207. Ibid.

208. Legislative Analyst’s Office. Retrieved from: http://www.lao.ca.gov/cup1195.html.


210. Ibid.

211. The Institute for Higher Education Policy. College Remediation: What It Is, What It Costs, What’ sat Stake. Washington, DC: The Institute for Higher Education Policy, December 1998,p. 20-24.


213. Starr P. The Social Transformation of American Medicine. New York: Basic Books, 1982.

214. Governor’s Proposed Budget for 1999-2000, Section on “Accessibility, Affordability,Accountability.” Retrieved from: http://www.dof.ca.gov/html/BUDGT9-0.HiEdN.htm.January 11, 1999.

215. Heidecker L. Private, For-profit Universities: Faculty Internship Project. Departmentof Anthropology, California State University, Sacramento, CA. Retrieved from: http://www.csus.edu/ssis/ forprofu.htm.

216. Ibid.

217. Ibid.

218. Center for the Health Professions and the Task Force on Accreditation of HealthProfessions Education. Working Papers. San Francisco, CA: Center for the HealthProfessions, June 1998.

219. California School-to-Career Net. Retrieved from: http://www.stc.cahwnet.gov.

220. Ibid.

221. Campbell B, and the California Department of Education School to Career. InfoLine. Spring 1998: 1(3).

222. Ibid.

261




262 223. California School-to-Career Net. Retrieved from: http://www.stc.cahwnet.gov.

224. National Center for Research in Vocational Education: School To Work, CollegeAnd Career: Review Of Policy, Practice, And Results 1993-1997. Retrieved from: http://ncrve.berkeley.edu/MDS-1144/.

225. California Department of Education, Health Career Education Program, School-to-CareerUnit, High School Teaching and Learning Division. Health Careers Education 2000: A ProgramGuide. Sacramento, CA: California Department of Education, 1998, p 24.

226. California Department of Education, Health Career Education Program, School-to-Career Unit, High School Teaching and Learning Division. Health Careers Education 2000: AProgram Guide. Sacramento, CA: California Department of Education, 1998, p.15.

227. California Department of Education, Health Career Education Program, School-to-Career Unit, High School Teaching and Learning Division. Health Careers Education 2000: AProgram Guide. Sacramento, CA: California Department of Education, 1998. p 24.

228. California Department of Education, Health Career Education Program, School-to-CareerUnit, High School Teaching and Learning Division. Health Careers Education 2000: AProgram Guide. Sacramento, CA: California Department of Education, 1998, p.17, 25.

229. California Department of Education, Health Career Education Program, School-to-Career Unit, High School Teaching and Learning Division. Health Careers Education 2000: AProgram Guide. Sacramento, CA: California Department of Education, 1998. p.17.

230. California Department of Education. California Partnership Academies. Retrieved from: http://cde.ca.gov/partacad/pver.html.

231. Ibid.

232. California Department of Education. Programs in Health Careers. Sacramento, CA:California Department of Education, 1995.

233. Health Occupations Students of America. Retrieved from: http://www.hosa.org.

234. California Department of Education, Health Career Education Program, School-to-Career Unit, High School Teaching and Learning Division. Health Careers Education 2000: AProgram Guide. Sacramento, CA: California Department of Education, 1998, p 43.

235. California Postsecondary Education Commission. Financing Postsecondary Education inCalifornia, 1985-2000. Sacramento, CA: California Postsecondary EducationCommission, Report 85-17, 1985. And California Postsecondary EducationCommission. Student Profiles, 1997. Sacramento, CA: California PostsecondaryEducation Commission, Meeting of August 24-25, 1997, Agenda Item 5.

236. State of California, Employment Development Department, Labor MarketInformation Division, California Occupational Guide Number 461. Retrieved from: http://www.calmis.cahwnet.gov/file/occguide/HOMEHA.HTM.

237. Ibid.


238. Gilbert NJ. Relationships: Home Care Aides’ Perceptions of their Interactions withCommunity Health Nurses. Caring. April, 1994:13(4), p. 24-8.

239. State of California, Employment Development Department, Labor MarketInformation Division, California Occupational Guide Number 442. Retrieved from: http://www.calmis.cahwnet.gov/file/occguide/NURSEAID.HTM.

240. Ibid.

241. Ibid.

242. Pear R. Neglect at Nursing Homes. The New York Times. Copyright 1998 The New YorkTimes Company. August 2, 1998.

243. Nursing Homes’ Shame. The Los Angeles Times. Copyright 1998 The Los Angeles TimesCompany. July 29, 1998. Editorial.

244. California Employment Development Department. Retrieved from: http://www.edd.cahwnet.gov.

263



Created by the University of California, San Francisco in 1992, the Center is an

outgrowth of the Pew Health Professions Commission. The mission of the Center

is to assist health care professionals, health professions schools, care delivery organizations

and public policy makers respond to the challenges of educating and managing a health care

workforce capable of improving the health and well being of people and their communities.

CENTER FOR THE

HEALTH PROFESSIONS

The California HealthCare Foundation is a private independent philanthropy established in

May 1996, as a result of the conversion of Blue Cross of California from a nonprofit

health plan to WellPoint Health Networks, a for-profit corporation.

The Foundation focuses on critical issues confronting a changing health care marketplace:

managed care, the uninsured, California health policy and regulation, health care quality, and

public health. Grants focus on areas where the Foundation’s resources can initiate meaningful

policy recommendations, innovative research, and the development of model programs.

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