240,000 advanced practice nurses and 66,000 physician assistants in 2004–2006. Over the years, these midlevel practitioners have increasingly gained the ability to obtain reimbursement for their services, but they still face considerable state-to-state variation in scope-of-practice laws, particularly in the amount of physician oversight they must have and whether they are allowed to write prescriptions. Many of these practitioners have found a congenial home in managed care or in large physician practices where they can perform triage, initial and simple treatment, referral, and patient education roles that improve physician productivity. A disadvantage of substituting these “midlevel” practitioners for physicians is that they may lack physicians’ wide range of diagnostic and therapeutic knowledge.

Another longstanding problem is the lack of racial and ethnic diversity in the nation’s health professional workforce. The lack of minorities in the professions is important for several reasons. Minority professionals are more likely to serve minority patients, increasing access to care for some underserved groups; in turn, many minority patients prefer being cared for by professionals of their own ethnicity and generally are more satisfied with the care received (IOM, 2004). Health care professionals who share their patients’ background and language are more likely to provide culturally competent services, which is especially important for patients who are recent immigrants or lack English proficiency.

African Americans, Hispanic Americans, and Native Americans constitute more than a quarter of the U.S. population, but are only nine percent of the nation’s nurses, six percent of physicians, and five percent of dentists (Sullivan Commission on Diversity in the Healthcare Workforce, 2004). Shortages of Asian-American health professionals are often ignored, because the number of Asian-American (or Asian international graduates) health professionals appears relatively high, compared to the size of the Asian-American population. This is misleading, because the Asian-American demographic category covers more than a dozen ethnic groups with starkly different cultures and languages—from Pakistan to Taiwan and Mongolia to Malaysia. Simply having an “Asian” health care provider does not necessarily meet the needs of individual Asian-American patients for culturally competent care.

At a time of workforce shortages, minority groups may represent a large, relatively untapped pool of potential health professionals. A 2004 IOM report recommended assessment of the effectiveness of the Health Resources and Services Administration (HRSA) workforce educational programs in increasing the number of minority graduates and additional



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