Ensuring Quality Cancer Care Through the Oncology Workforce: Sustaining Care in the 21st Century: Workshop Summary (2009)

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Supply and Demand in the Health Care Workforce I n addition to the U.S. population growing by 25 million people each decade, the aging of the American population is indisputably boost- ing the demand for cancer services, as well as contributing to a lack of health care professionals, stated Mr. Edward Salsberg, Senior Director of the Center for Workforce Studies at the Association of American Medi- cal Colleges (AAMC). Between 2000 and 2030, the number of people in the United States over the age of 65 is expected to double. This elderly population makes twice as many physician visits as those under 65, and the incidence of cancer is far higher for the elderly than younger age groups. In addition, the number of average visits to physicians by people over the age of 45 has risen significantly over the past 15 years (NCHS, 1990, 2000, 2005). “We worry that this trend is going to continue,” said Mr. Salsberg, who noted that the high expectations for medical care held by the baby boom generation are helping foster that trend. Mr. Salsberg pointed out that another factor contributing to the higher demand for health care services is the increasing pace of medical advances. One study found that most medical advances, such as within the oncology arena, have increased the demand for services. However, medical advances that prevent obesity may be an exception to this general rule. There is a rising number of health problems linked to an increasingly obese population. As medical advances that prevent obesity develop, this may decrease the demand and use of health care services to some degree (RAND Corporation, 2005).  

 ENSURING QUALITY CANCER CARE On the supply side, of particular concern are the large number of aging physicians heading into retirement. These physicians are being replaced with a new generation of doctors who prefer to work part-time or in specialties, such as dermatology or neurology, that are less likely to have demanding on-call responsibilities. “Generation X individuals see [fewer] patients. They typically place a greater premium on lifestyle factors than their older counterparts, so that would decrease the amount of supply,” said Dr. Dean Bajorin, Member of the Memorial Sloan-Kettering Cancer Center and Professor of Medicine at Weill Medical College of Cornell University (Hauer et al., 2008). Although statistics from the Bureau of Labor indicate that health care jobs are going to grow more than twice as fast as non–health care jobs in the next decade, physicians represent a decreasing share of that expand- ing health workforce (Center for Health Workforce Studies et al., 2008). Mr. Salsberg noted that some health professions, such as nurse aides and home health aides, require a minimal amount of education and training and, as a result, large numbers of these professionals can be graduated quickly to respond to the increasing demands on the health care system. Unfortunately, this is not the case for physicians, who require between 10 and 16 years of education and training. “We’re trying to look at what are the needs going to be in 2015 and 2020, because unless we act now, we’re not likely to meet those future needs,” Mr. Salsberg said. Assessing the future needs of physicians who provide oncology care includes assessing the future needs of physicians outside of oncology. As Mr. Salsberg noted, a large percentage of patients with cancer do not see oncologists for their cancer care and chemotherapy, because of the unequal geographic distribution and difficulty in accessing an oncologist (Erikson et al., 2007). In addition, a large number of physician sub-specialties besides oncology are involved in treating cancer patients, including gastro­enterology, surgery, dermatology, radiology, urology, gynecology, ­hematology, pathology, pulmonology, and internal or family medicine. Shortages of physicians in many specialties will affect the quality of cancer care. Shortage of Physicians Many health specialties, including oncology, currently report a shortage of physicians. Despite an expected 21 percent increase in medical school enrollments between 2002 and 2012, the number of residencies has only increased 8 percent over the past 5 years (Salsberg et al., 2008). Dr. Bajorin, 

SUPPLY AND DEMAND IN THE HEALTH CARE WORKFORCE  in particular, stressed the increasing lack of general surgeons who are involved in cancer care. Significant numbers of surgeons are subspecializing. According to a 2005 survey of surgical residents, over 50 percent planned on pursuing subspecialty training, and only 15 percent planned on enter- ing the workforce as a general surgeon (Incorvaia et al., 2005). Liability issues have also been problematic for general surgeons, who are confronting high insurance premiums. This is especially true in states that do not cap financial awards of malpractice lawsuits, which leads to physicians altering or limiting their practice due to the threat of being sued (MMS, 2007; Thorpe, 2004). Using a methodology for making projections developed by the Health Resources and Services Administration, Mr. Salsberg and his colleagues projected that by 2025 there will be a shortage of between 124,000 and 160,000 full-time physicians, after considering a variety of scenarios for future supply and demand (see Figure 1) (AAMC, 2008). Even with 950,000 FTE physicians (excluding residents) Most Plausible Demand 900,000 Baseline Demand Most Plausible Supply 850,000 Baseline Supply 800,000 750,000 700,000 650,000 600,000 2005 2010 2015 2020 2025 Year FIGURE 1  Projected full-time physicians, baseline and most plausible scenarios, 2006-2025. By 2025, there will be a shortage of between 124,000 and 160,000 full- time physicians. SOURCE: Salsberg presentation (October 20, 2008) and the Association of American Medical Colleges. 2008. The complexities of physician supply and demand: Projections through 2025. https://services.aamc.org/Publications/index.cfm?fuseaction=Product. Figure 1-NEW displayForm&prd_id=244&prv_id=299 (accessed January 31, 2009). Reprinted with permission from the Association of American Medical colleges. 

 ENSURING QUALITY CANCER CARE an expansion of graduate medical education (GME) training positions, the demand will still exceed the supply of physicians in this model (see Figure 2). “We could have a terrible crisis,” said Mr. Salsberg. Mr. Salsberg added, given that the expected shortage of physicians is not likely to be substantially relieved by newly trained physicians alone, it is important to think about strategies that will ensure access to quality care. “As the difference between supply and demand grows, people will lose access to needed services, and both care and quality can drop. The other reality is that underserved communities are likely to feel the shortage the most because the wealthy communities are clearly likely to outbid poor communities for limited resources,” he said. 900,000 Baseline Demand Additional Supply from GME Expansion FTE Physicians (excluding residents) Baseline Supply 850,000 800,000 750,000 700,000 650,000 2006 2009 2012 2015 2018 2021 2024 Year FIGURE 2  Projected national supply and shortfall of physicians with GME expansion. SOURCE: Salsberg presentation (October 20, 2008) and the Association of American Medical Colleges. 2008. The complexities of physician supply and demand: Projections through 2025. https://services.aamc.org/Publications/index.cfm?fuseaction=Product. FIGURE 2 New displayForm&prd_id=244&prv_id=299 (accessed January 31, 2009). Reprinted with permission from the Association of American Medical colleges. 

SUPPLY AND DEMAND IN THE HEALTH CARE WORKFORCE  Shortage of Nurses The current and predicted future shortage of nurses is also problematic. Dr. Peter Buerhaus, the Valere Potter Distinguished Professor of Nursing and Director of the Center for Interdisciplinary Health Workforce ­Studies, the Institute for Medicine and Public Health, Vanderbilt University Medi- cal Center, reported that there is an ongoing shortage of nurses that began in 1998. This is the longest lasting shortage of nurses in over half a cen- tury, and was sparked by a lack of supply (i.e., too few nurses entering the workforce) rather than by an increasing demand for nursing services. In 2002, the vacancy rates for nursing positions were as high as 13 percent, and currently are estimated to be roughly 8 percent or lower (AHA, 2007; Buerhaus et al., 2005b). The Bureau of Labor Statistics data predicts that close to a million new nurses will be needed over the next decade, both to fill new jobs and to replace vacancies resulting from retiring nurses (see Figure 3) (Martiniano, 2008). However, Dr. Buerhaus stated that he expects nurse vacancy rates to drop with the current economic slump, based on his analyses of the registered nurse (RN) labor market. He discussed a number of trends in RN employment, including the fact that higher wages usually induce more RNs to enter the workforce and work longer hours. In addition, a bigger stimulus for RNs 3 2.5 Nurses in Millions 2 Demand 1.5 Supply 1 0.5 0 2000 2005 2010 2015 2020 Year FIGURE 3  The United States faces a potential shortage of more than 1 million nurses by 2020. SOURCE: Sowers presentation (October 21, 2008). Data from the Human Resources and Services Administration. Figure 3 New 

 ENSURING QUALITY CANCER CARE entering the workforce is what he called the RNs’ “household wealth,” which is driven largely by the nurses’ spouses’ earnings. Since three out of four RNs are married, changes in RNs’ spouses’ economic well-being can greatly impact RNs’ decisions to enter or leave the workforce (Buerhaus et al., 2007b). When overall employment and earnings are up in the United States, nurses tend to work fewer hours or retreat altogether from the workforce. However, when there is high unemployment, RNs are more inclined to work, and to work long hours. “As this economy continues to unravel, and if unemployment goes up, which most economists are predicting, you’re going to have another surge of RN employment eliminating whatever excess capacity there is,” Dr. Buerhaus said. The elimination of the current nursing shortage, due to the poor economic situation, does not mean the nursing shortage crisis is solved, Dr. Buerhaus cautioned. There are many long-term factors that suggest that the supply of future nurses is inadequate and faces potential problems. These include the fact that many currently practicing nurses are older and that there is an increasing proportion of foreign-born nurses who U.S. hos- pitals sponsor on work visas. In 2012, the largest age group of RNs will be between 50 and 60 years old (Buerhaus et al., 2008). Many of these older nurses are expected to retire by 2025. The older nurses that remain will have experienced years of lifting and pulling patients, and other physical strains that are likely to foster frequent injuries. The long recovery periods required for healing these types of injuries will further decrease nurse workforce s ­ upply, according to Dr. Buerhaus. As a result, Dr. Buerhaus predicts the supply of nurses will increase for the next several years, but starting around 2015, when many nurses opt for retirement, the supply of nurses will level off. He projects a shortage of 500,000 full-time nurses in 2025 (Buerhaus et al., 2008). The predicted shortage of nurses developing midway through the next decade will probably foster an increasing number of foreign-born and -­educated RNs, Dr. Buerhaus pointed out. This can be problematic and affect the quality of nursing care as nursing errors and mistakes are often related to failures in communication. Although foreign-born nurses may pass an English language test (i.e., TOEFL—Test of English as a ­Foreign Language), they may not detect cultural nuances and nonverbal cues. How- ever, Dr. Buerhaus added that there are no data to document that this is a problem. Currently, foreign-born and -educated RNs comprise 15 percent of the nursing workforce in the United States (Buerhaus et al., 2008). Dr. Buerhaus suggested that researchers should explore how increasing this 

SUPPLY AND DEMAND IN THE HEALTH CARE WORKFORCE  number may affect the quality of care. Ms. Pamela Malloy, the End-of-Life Nursing Education Consortium Project Director at the American Associa- tion of Colleges of Nursing (AACN), added that the evidence does show that foreign-born nurses who do not have English as their primary language do not tend to do well on the state board exams. Contributing to the shortage of nurses is a lack of faculty to train them. For example, to be qualified to teach nursing at the undergraduate level, a Masters in Nursing is required. Dr. Kathi Mooney, Professor at the Univer- sity of Utah College of Nursing, noted that the AACN data indicate that there were over 40,000 qualified applicants to colleges of nursing denied admission in 2007. The primary reason cited for such denials was a faculty shortage. A recent AACN survey also found that 85 percent of nursing schools have faculty vacancies or need more faculty members but do not have a budget to pay them (AACN, 2007). Most openings for nursing fac- ulty are for doctoral candidates. Despite the need for Ph.D. nursing faculty, the 2007 Ph.D. enrollment in nursing was up by less than 1 percent from pervious years (AACN, 2008b). Convincing nurses to pursue Ph.D. degrees is difficult, Dr. Mooney noted, because doctorate- or even masters-level prepared nurses in clinical positions can earn a significantly higher salary in health care administra- tion or as nurse practitioners (NPs) than they can as faculty. Other reasons cited for a lack of nursing faculty in the AACN survey were difficulties in finding faculty with the right qualifications or specialty mix, and problems finding faculty willing or able to conduct research (AACN, 2007). Also a substantial contributor to the shrinking of nursing faculty is the aging of current nursing professors. The average age of doctorate-level faculty in nursing is 53.5 years, whereas the average age of doctorate-level faculty holding the rank of professor is 59 years (AACN, 2008a). Compound- ing the problem is the fact that nursing faculty tend to retire early, with AACN data showing 62.5 as the average age of nursing faculty retirement (see Figure 4) (Berlin and Sechrist, 2002). Shortage of Allied Health Care Professionals Dr. Michael Ahearn, Dean of the University of Texas M. D. Anderson Cancer Center’s School of Health Sciences, presented data to show that laboratory and radiology technicians (the allied health care workforce) also face a current and future workforce shortage, and the shortage may be even greater than the shortage of physicians and nurses detailed by 

10 ENSURING QUALITY CANCER CARE Number of Nurse Educators 32,000 24,000 16,000 8,000 0 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 Year Remaining Nurse Educators Planned Retirements FIGURE 4  The shrinking ranks of current nurse educators. SOURCE: Mooney presentation (October 21, 2008) and the NLN/Carnegie National Survey of Nurse Educators: Compensation, Workload, and Teaching Practice, 2006, Preliminary Findings, National League for Nursing, New York. New Figure 4 o ­ thers. In 2001, Tommy Thompson, Secretary of the U.S. Department of Health and Human Services (HHS), declared that the shortage of allied health care workers was a greater menace to the delivery of health care than the well-publicized nursing shortage (Hillborne, 2008). He added that Edward O’Neil, the Director of the Center for Health Professions, claimed that “as important as shortages in nursing, pharmacy, medicine, and even dentistry might become, they will fail to reach the depth of the looming crisis in the allied health workforce” (Center for the Health Professions, 2008). Allied health professionals compose 60 percent of the health care workforce, and despite this large number, laboratories nationwide are experiencing a shortage of qualified technologists (Health Workforce Solu- tions, 2007; Passiment, 2006). The Bureau of Labor Statistics projects that by 2015, the United States will need 81,000 additional clinical laboratory technologists to replace retiring staff, and another 68,000 to fill newly created positions (see Figure 5) (Hillborne, 2008). With fewer than 4,700 current graduates from combined laboratory science programs, the number 

SUPPLY AND DEMAND IN THE HEALTH CARE WORKFORCE 11 400,000 350,000 300,000 Workers Number Needed 250,000 Estimated Workforce 200,000 Shortage 150,000 100,000 50,000 2006 2010 2015 Year FIGURE 5  Projected gaps in the supply and demand for clinical laboratory science workforce. New Figure 5 SOURCE: Ahearn presentation (October 21, 2008) and McClure, K. J. 2007. Texas Laboratory Health Care Workforce: Meeting the Needs in 2015. Unpublished doctoral dis- sertation, The University of Texas Health Science Center, The School of Public Health, Houston, Texas. of annual graduates will have to be increased three- to four-fold to meet the estimated demands in these professions, Dr. Ahearn noted. Unfortunately, there are inadequate numbers of allied health care education programs. Between 1970 and 2005, there has been a significant decline in both the number of education programs for health technolo- gists as well as the number of graduates from such programs in the United States. A 70 percent decline in the numbers of health technology programs in the United States since 1975 has left only 240 operational at the present time, according to Dr. Ahearn. This is an insufficient number to train the rapidly retiring workforce (Anderson, 2007). The American Society for Clinical Pathology claims that the laboratory personnel labor force is aging 78 percent faster than the general U.S. labor market, because the pace of younger, newly trained, laboratory personnel entering the workforce has slowed significantly (ASCP, 2004). In addition, currently there are fewer than 40 accredited cyto­ technology training programs in the United States (ASCP, 2008), gradu- ating fewer than 270 technologists annually. This number falls far short 

12 ENSURING QUALITY CANCER CARE of even replacing the attrition rate reported for this particular profession. Similarly, there are only six ­cytogenetic technology training programs in the nation, and they graduate fewer than 41 students annually. Despite the expanding role that molecular genetic technology is playing in both diag- nostic clinical and research laboratories, at the present time, there are only 6 accredited genetic technician academic programs in the United States, with an annual output of 60 graduates (NAACLS, 2008). Also, listed on the “endangered list” of allied health professions are ­baccalaureate degree programs in diagnostic imaging, radiation therapy, and health dosimetry, Dr. Ahearn noted (JRCERT, 2009). There also will be a shortage of imaging technologists soon. Despite the increasing complexity of imaging procedures, which has created a demand for better-prepared technologists, the American Society of Radiologic Technologists reports that if the current academic enrollment, attrition, and graduation levels remain constant, there will be a 14 percent shortage of even entry-level imaging personnel by as early as 2012 (ASRT, 2005). Addi- tionally, there are only 6 accredited academic health dosimetry programs in the nation, with a total annual output of only 55 graduates, which means that all of the other dosimetrists are trained on the job with variable levels of instruction, Dr. Ahearn said (JRCERT, 2009).