• Mission & Governance
• Services Overview
• How to Get Involved
• Standing Committees
• NCSL Foundation

• Issue Areas: A-Z
• State-Federal Relations
• NCSL Standing Committees
• News from D.C. and the States

• About State Legislatures
• Elections, Campaigns & Redistricting
• NCSL's StateConnect Directory
• Web Sites

• Online Guide to NCSL Services
• Staff Sections and Networks
• Meetings & Professional Development
• Staff Directories

• Meetings Calendar
• Online Registration
• Meetings Home Page
• Legislative Summit

• Bookstore
• State Legislatures Magazine
• NCSL's StateConnect Directory

Frequently Asked Questions...

The Health Care Workforce

· What specific questions should lawmakers ask of their state officials who are charged with health professions education?

Glossary

Notes

Staff Contact

Other Sources

Why should public policymakers be concerned about the health care workforce?

The health care workforce is a major, diverse and vital industry frequently used by the public. Yet, the competence and quality of care the public receives from the health workforce typically is taken for granted. The services provided by the health care workforce command significant government oversight for the sake of public protection and accountability.

Health care is one of the largest industries in the country, with about 11.3 million jobs, including those who are self-employed. Almost one-half of all health services jobs are in hospitals; another one-third are in either nursing and personal care facilities or physicians' offices. More than 90 percent work in the private sector; the remainder work in state and local government hospitals. In addition to wage and salary workers, an estimated 446,000 workers in the industry were self-employed in 1998. Of these, about 70 percent were in offices of physicians, dentists or other health practitioners.

About 14 percent of all wage and salary jobs created between 1998 and 2008 will be in health services. Twelve of the 30 occupations projected to grow the fastest are concentrated in health services. Most jobs require less than four years of college education.

Two-thirds of all private health care establishments are offices of physicians or dentists. Although hospitals comprise less than 2 percent of all private health care providers, they employ nearly 40 percent of all workers (table 1). When government hospitals are included, the proportion rises to almost half the workers in the industry. More than half of all non-hospital health providers employ fewer than five workers. On the other hand, almost two-thirds of hospital employees were in institutions that employ more than 1,000 workers.

Table 1.

Source: Bureau of Labor Statistics, U.S. Department of Labor, 2000.

Employment in health services will continue to grow for a number of reasons. The elderly population, a group with much greater than average health care needs, will grow faster than the total population between 1998 and 2008, increasing the demand for health services, especially for home health care and nursing and personal care. Advances in medical technology will continue to improve the survival rate of severely ill and injured patients, who then will need extensive therapy. In addition, medical group practices and health networks become larger and more complex, they will need more managerial and support workers.

Employment growth in the hospital segment will be the slowest within the health services industry, as it consolidates to control costs and as clinics and other alternate care sites become more common. Hospitals will provide more outpatient care, rely less on inpatient care, and streamline health care delivery operations. Job opportunities, however, will remain plentiful because hospitals employ a large number of people. The demand for dental care will increase due to population growth, greater retention of natural teeth by middle-aged and older people and greater awareness of the importance of dental care and ability to pay for services. Rapid growth in other health services will result mainly from the aging of the population, new medical technologies, and the subsequent increase in demand for all types of health care. Also contributing to industry growth will be the shift from inpatient to less expensive outpatient care, made possible by technological improvements and Americans' increasing awareness and emphasis on all aspects of health. Various combinations of all these factors will assure robust growth in this massive, diverse industry.

The fastest growth is expected for workers in occupations concentrated outside the inpatient hospital sector, such as medical assistants and personal care and home health aides. Because of cost pressures, many health care facilities will adjust their staffing patterns to lower bottom-line labor costs. Where patient care demands and outside regulations allow, health care facilities will substitute lower-paid providers and cross-train their workforce. l

Is there a shortage of certain health care professionals?

Typically, the supply of health care professionals in most states is either inadequate or maldistributed. Today, much of the attention given to ensuring better access to health care (for low-income children, in particular) narrowly centers on improving insurance coverage. Yet, simply having health insurance does not guarantee adequate or appropriate access to needed services of the health care workforce, nor does it determine use of their services. l

Source: National Journal, American Healthline, June 2000.

The supply of health care professionals is either inadequate or maldistributed in the following ways.

Because we have too many specialty physicians in this country and health personnel in hospital emergency rooms deliver excessive amounts of episodic treatment, large numbers of people lack access to continuous primary care. A shortage of primary care professionals (i.e., physicians, nurse practitioners) in many places hampers staffing by many managed care organizations.

By geography

Many rural and inner city areas lack physical access (e.g., long distances between home and the nearest health care provider, poorly maintained roads, lack of public transit) to a variety of health professionals. For example, although about 20 percent of the population live in rural areas, less than 11 percent of the nation's physicians are practicing in non-metropolitan areas. In most medically underserved areas, a shortage exists of physicians, dentists and other health care professionals, including nurse practitioners and physician assistants. About 17 percent of the U.S. population (more than 44 million people) reside in federally designated "health professional shortage areas." More than 2,200 physicians are needed in these areas to remove the designations for primary care.

In many health professions, men, women or certain minorities are underrepresented by specialty or geographic location. This may hamper efforts by health professionals to care for certain culturally diverse patient populations if they are not culturally competent to understand and serve their needs. l

Do certain population segments typically lack access to health care professionals?

In addition to residents of many rural and inner-city communities, some segments of the population-pregnant women and children, the handicapped and the growing elderly population, for example-may have unequal or inappropriate access to the services of certain health professionals. For example, many disadvantaged children suffer from poor oral health because they do not have adequate access to a dentist for basic dental care. Black Americans, mainland Puerto Ricans, Mexican Americans, and American Indians and Alaska Natives have some of the worst health indicators among U.S. population groups and also are not able to obtain some technological and surgical procedures and routine health care preventive services as frequently as whites do.1

It is thought that physicians from racial and ethnic minority groups can help improve access to care for minority groups. These minority physicians are more likely than white physicians to practice in underserved areas and are more likely to care for minority, poor, underinsured and uninsured people. Yet, minorities are underrepresented at all levels of medicine. In 1997, black Americans, Hispanics, and American Indians and Alaska Natives represented approximately 23.6 percent of the population, while only 12.2 percent of all medical school enrollees were underrepresented minorities. Between 1996 and 1997, there was a 7.1 percent decline in underrepresented minority new entrants to U.S. medical schools. Moreover, minorities who attend medical school may find themselves with few minority role models and mentors, since minorities also are greatly underrepresented on medical school faculties.2

What is the role of states in regulating and licensing health care professionals?

The states are the longstanding regulatory agents for health care professionals. States:

· Determine and measure minimum competence through licensing and certification;

· Discipline providers; and

· Identify and enforce scopes of practice for health professions. l

What issues currently face states in the regulation of health care professionals?

As the use of technology evolves within our rapidly changing health delivery system, various health professions are being redefined, and many educators and practitioners are reconsidering the credentials needed to practice within the profession. For many non-physicians, changes in their practice capabilities brought on by changes in their education are putting pressure on government regulators, policymakers and health care organizations to sort out and enforce new boundaries for health professions practice.

Until recently, there has been little change in the type and scopes of practice of the approximately 40 health professions regulated by states. However, the following trends are forcing renewed attention to health professions licensure and regulation by states.

· Major growth is occurring in the number and diversity of non-physician professions, many with increasing overlapping scopes of practice with both physicians and other non-physicians. Arising "turf battles" are putting enormous new pressures on state policymakers. For example, several states are witnessing heated debates between ophthalmologists and optometrists over who has the right to practice laser surgery, and between family practice physicians and nurse practitioners, as well as general dentists and dental hygienists, over who has the authority to deliver independent primary care services.

· The advent of managed care and greater market competition is placing new pressures on:

· All professions to seek new or enhanced payments from insurers.

· Health care organizations to use many health professions in different ways that create both new opportunities and additional stresses in the work environment. To reduce costs, for example, most hospitals would like to have the flexibility and authority to use interchangeably certain allied health professionals such as lab and x-ray technicians.

· New attention to the medical errors problem and other consumer concerns are prompting government officials to find new ways to regulate and discipline health care professionals, ensure continuing competence of these professionals, and make more information available to the public. l

What is the role of states in assuring an adequate supply of health care professionals? What are the major financing mechanisms and other strategies used to address this goal?

The role of state government in supporting the education and training of health professionals is well established. Historically, state general revenue appropriations for medical, nursing and allied health education have been directed largely to undergraduate training.

In 1998, medical school revenues from state and local government general funds were worth more than $3 billion. Although the amount of funds states devote to medical education has about doubled since the early 1980s, the proportion of medical school revenue from state and local appropriations in 1998 was only 8 percent compared to 23 percent in the early 1980s (tables 2 and 3).

Source: Association of American Medical Colleges, 2000.

Source: Association of American Medical Colleges, 2000.

This shift in the payer mix of medical schools reflects, in part, the growing importance to the programs of patient care or faculty practice plan revenues. About 60 percent of all medical schools are state-owned or state-related and receive state appropriations. Some states also subsidize private schools. Many nursing and allied health training programs receive public funds as part of a state's general appropriations to support state colleges and universities. In many states, these funds are made available through a board of higher education. l

Medicaid Support for Graduate Medical Education

Since the inception of the Medicaid program in the middle 1960s, many states have paid what they believe to be their fair share of clinical training or graduate medical education (GME) costs. Although Medicaid programs are not obligated to pay for GME, most states historically have made these payments under their fee-for-service program. Generally, state support for GME takes the form of some or all of the following.

· Operating subsidies to teaching hospitals and clinics;

· Direct support of clinical education programs such as residencies, internships and preceptorships; and

· Medicaid reimbursement to hospitals for certain teaching costs.

Most states also provide specific funding for training in family medicine and primary care residencies. Legislators in many states often view support for residency training as a solution to rural residents' and indigent populations' problems of access to primary care. Recent studies also have found that state support is important to many nurse practitioner and physician assistant training programs.

State government support for the health care workforce first evolved in the 1940s in various forms, including appropriations for health professions education and profession scholarship and loan initiatives. In the 1960s with the advent of the Medicare and Medicaid programs, significant government support began for graduate medical education and some nursing education.

Despite legislated missions, both state and federal financing of health professions education were largely unrestricted in regard to addressing identified public needs until as early as the 1960s. With the addition of titles VII and VIII to the U.S. Public Health Service Act and national reports that indicated significant shortages of certain health professionals, the federal government began to develop the earmarked initiatives described above. To date, however, the effects of these initiatives appear insignificant in regard to improving health professions supply in shortage areas.

Beginning in the 1980s, many states began to require recipients of many of their health professions scholarship and loan programs to complete some service in a medically underserved area of the state as repayment for the state's financial assistance. Over time, many of these programs have been refined to increase the likelihood that a certain proportion of recipients of these scholarships and loans might remain in underserved communities upon completion of their obligation. Similar to federal programs, it is not clear how effective these initiatives have been in improving recruitment and retention of health professionals in these settings.

As states move rapidly to enroll their Medicaid population in managed care, Medicaid support for GME and related costs is changing. Although Medicaid rates to managed care organizations (MCOs) may include historical payments for graduate medical education, MCOs are not bound to distribute these funds to hospitals that have GME programs or to provide GME themselves. A small but growing number of Medicaid programs are making an explicit connection between distributed GME funds and training program accountability. Ten states require that some or all Medicaid GME payments be directly linked to state policy goals that are intended to vary the distribution of or limit the health care workforce. The goal of encouraging the training of physicians in certain specialties (e.g., primary care) is the most common application. In general, it is too early to know if these financing strategies will effectively lessen the problems of physician maldistribution in most states.

In recent years, some state Medicaid programs have tried to improve service delivery and expand access to basic health services by improving their support for the health care workforce. Among the most popular tactics have been to raise provider payment rates, simplify billing procedures and implement aggressive recruitment programs to increase provider participation. Such efforts often have fallen short of their goal, however. Provider payment rates in general remain low under both fee-for-service and managed care, for example. Although Medicaid managed care, in contrast to the fee-for-service system, often is associated with greater provider participation and an increase in the proportion of individuals who report having a regular source of primary health care, many states recently have reported that several plans no longer are participating in the program because of cuts in capitation rates. l

What is the role of the federal government in assuring an adequate supply of health care professionals? What are the major financing mechanisms and other strategies used to address this goal?

More recently, the federal government also is viewed as being responsible for assuring an adequate health workforce supply by financing the education and training of many health professionals through institutional funding and individual scholarships and loans and by conducting limited health workforce planning and research.

The federal government supports health professions education through a variety of sources. The largest source of funding for education is the Medicare program. Most Medicare funding is allocated for graduate education (residency training) in medicine and flows mainly to teaching hospitals. A much smaller amount of Medicare funding is available for education in dentistry, podiatry, nursing and certain allied health professions (cytotechnology, dietetics, hospital administration, inhalation therapy, medical records, medical technology, occupational therapy, pharmacy, physical therapy and x-ray technology).

Although much smaller in terms of total expenditures, targeted grant programs administered by the Bureau of Health Professions and the Centers for Disease Control and Prevention also are critical sources of funding. The Bureau of Health Professions administers various grant programs authorized under titles VII and VIII of the Public Health Service Act. Although Title VII and Title VIII grant programs provide a much smaller amount of funding than Medicare, these programs are important sources of support for community-based and interdisciplinary education because most are targeted to promoting these types of educational experiences. Programs at the Centers for Disease Control and Prevention focus on educating health professionals about public health matters and on enhancing the knowledge and skills of practicing public health professionals.

The federal government also encourages the placement of health professionals in health professional shortage areas through the National Health Service Corps (NHSC). Congress created the NHSC in the 1970s to address the most critical primary care needs of rural communities. (The needs of urban neighborhoods soon became equally important.) The program increases access to primary care services and reduces health disparities for people in health professional shortage areas by assisting communities through site development and the use of scholarships and loan repayment to prepare and place community responsive, culturally competent primary care clinicians. During the past 28 years, the NHSC has made a concerted effort to reduce health professions shortages. Yet, the current group of NHSC clinicians placed in medically underserved communities meets just 12 percent of overall identified need. The NHSC Revitalization Act of 1990 authorized its continued existence through the year 2000. l

What can state policymakers do to ensure an effective and adequate supply of health care professionals?

The interest by many states to improve the health workforce is manifested in state efforts to maximize effective licensure and regulation procedures that govern health professions and to pressure health professions schools and teaching hospitals to train more generalists and to improve the overall supply of health professionals in rural and medically underserved communities. These efforts are a major means for states to:

· Achieve some congruence between public need and safety and the existing supply of health professionals, and

· More carefully account for all state contributions to health professions education and regulation.

To develop and enact effective health workforce programs and policies, public policymakers should resolve to ask themselves the following questions. l

What specific questions should lawmakers ask of their state officials who are charged with health professions regulation?

· Are state workforce regulatory policies:

· Promoting effective health outcomes and protecting the public from harm?

· Holding regulatory bodies accountable to the public?

· Respecting consumers' rights to choose their health care providers from a range of safe and reasonable options?

· Encouraging a flexible, rational and cost-effective health care system that allows effective relationships among various health professions?

· Facilitating professional and geographic mobility of competent providers? l

What specific questions should lawmakers ask of their state officials who are charged with health professions education?

· In general, are we training the right professions in the right places for service in the right places with the right competencies? A growing number of state officials are demanding greater public accountability of public funds to address this question.

· What does the public want from their health professions schools? What are the public's priorities for their large academic health centers: appropriate health care workforce vs. ability to attract federal research dollars vs. biotechnology vs. institutional prestige vs. public health vs. community service?

· How effectively are publicly supported health professions schools preparing professionals to meet public needs?

· How can government improve the chances that publicly supported health professions schools will prepare health professionals to meet public needs?

· What is an appropriate and fair level of government support for graduate health professions education? Should public support for graduate training be directed toward creating new programs or strengthening existing programs? l

GLOSSARY

Osteopath: Osteopathic medicine is a distinctive form of medical care founded in the late 1800s on the philosophy that all body systems are interrelated and dependent upon one another for good health. Osteopathic physicians use all the tools available to allopathic physicians including prescription medicine and surgery. When appropriate, they also incorporate osteopathic manipulative treatment-a set of manual medicine techniques that may be used to relieve pain, restore range of motion, and enhance the body's capacity to heal-into their regimen of patient care.

Nurse Practitioners: Nurse practitioners (NPs) are registered nurses who have completed advanced training in primary care and other specialties. Functions performed by NPs typically include health assessment, physical examinations, management of minor acute and chronic illnesses, development and coordination of plans of care, patient education, and health promotion/disease prevention activities.

Graduate medical education: Graduate medical education (GME) is the process for providing academic and clinical education to physicians after they have graduated from an accredited medical school. GME typically occurs in teaching hospitals or other health care settings, which provide the clinical setting for the advanced training of physicians. l

NOTES:

1 Council on Graduate Medical Education, Twelfth Report: Minorities in Medicine (Rockville, MD: U.S. Department of Health and Human Services, May 1998).

2 Ibid.

STAFF CONTACT:

OTHER SOURCES:

BACK TO TOP