HSCI 678 Intro to US Healthcare System Health Services Workforce Chapter 8 Tracey Lynn Koehlmoos, PhD, MHA

Roemer Model Where are we now? Resource Production –Workforce and hospitals –Research and technology Where have we been? –Organization of Programs –Management –Economic Support

Health Services Workforce Largest Industry in the US 11.9 million workers and growing! MDs: receive 20% of all personal health expenditures, control 75% of health expenditures Nurses, 2 million plus, largest group Many more allied professionals

Physicians Leadership/entry role in health system Historical autonomy Challenges –Doctor as businessman –Reduced fees –Insurers seek cost containment –Utilization review But first…

Medical History 101 US medical profession followed Brits. Apprenticeships, no standardized programs 1846—AMA founded, licensing & training –More standardization –More science and research

The Flexner Report 1910 by Abraham Flexner and AMA Visited 131 US and Canadian med schools Found wide variation in all aspects Recommended only 31 should stay open Johns Hopkins, ideal model Closed all but 2 Black medical schools

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

Graduate Medical Education GME, 3-7 year residencies for specialty Residents receive stipends Each GME costs Fed $70K Medicare and Medicaid, largest payers of GME No centralized controlling authority # Residencies > # Medical Graduates

Who fills the remaining slots? International Medical Graduates (IMGs) Formerly known as FMGs 1: to provide foreign MDs with training 2: Inexpensive labor for teaching hospitals 3: Augment supply of US physicians IMGs will work in places US physicians will not: Inner City Mental Hospitals Prisons

What do they do?

Supply and Demand 813,770 Physicians in US (2000) 2/3 Specialists Inadequate distribution of providers Demand, hard to predict Supply, easier to control –Number of Medical School Slots –Number of IMGs based on policy

Specialists v. Generalists Generalists: FP’s, Internal Medicine 2/3 of physicians are specialists/subspec. No emphasis on producing more FPs No quick fix Managed Care emphasizes the Primary Care Provider (Generalist)—but the idea has not caught on in the US

Physician Summary No easy way to predict demand There may be an oversupply –True in some areas and specialties –Undersupply in other areas and generalists Specialist receive higher reimbursement and more prestige than Generalist Generalists are the hub of Managed Care- sort of…

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

Midlevel Practitioners Physician Assistants (PAs) –Post-Vietnam, medical corpsmen –20-36 months training –Primary care role good for Managed Care –55% associated with specialist practices –Issues of professional territorialism –Licensure restriction

Midlevel Practitioners Advance Practice Nurses (APNs) Nurse Mid-Wives (4,000) Nurse Practitioners (58,500) No national standard Require physician oversight No direct reimbursement to APNs

Nurses Largest group in the medical workforce More than 2 million active nurses 2/3 work in hospitals Five levels of nurse education –CNA—on the job, no certificate –LPN—12 month program (state license) –RN—hospital diploma, AA, BA (state license) –APN—Midwife, ARNP –Clinical specialist—MS (also PhD, ND)

Nursing Shortage US-wide, expected to worsen Aging nurse workforce (43 average age) By 2010, 20% below requirements Reality of Nursing: –High entry salary, relatively low increase –Work environment complaints –Cultural change in US

Pharmacists and Dentists Pharmacists: 200,000+ –5-6 years of training –Dependent on MDs to write prescriptions –Increase in elderly patients, increase in internet and mail order prescriptions Dentists: 170,000 –No dependence on physicians! –Have successfully treated decay –Must find other areas to concur including MC

Health Service Administrators Highly trained business people and managers (60,000) Masters prepared (MHA, MBA, MS) Flexibility and leadership –Strategic planning and marketing –Stay current on technology and policies –Accounting and financial management –Clinical management and physical plant

Workforce Summary Largest segment of the US workforce More women becoming physicians, PAs Aging of the nursing workforce Racial and Ethnic disparities in all areas