Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 15
4
Supply and Demand
Good information about the allied health workforce is critical to good
decision making, and three speakers at the workshop looked specifically at
data issues as they relate to the supply and demand for allied health work-
ers. Harold Jones, dean of the School of Health Professions at the Univer-
sity of Alabama at Birmingham, examined federal data sources and some of
the limitations of those data in projecting supply and demand. Erin Fraher,
director of the Health Professions Data System at the University of North
Carolina at Chapel Hill, described the data collection and analysis system
in North Carolina, which serves as an example for health care workforce
planning. Finally, Jennifer Nooney, management analyst within the Health
Resources and Services Administration’s (HRSA’s) National Center for
Health Workforce Analysis, outlined the effort being undertaken by HRSA
to develop a minimum dataset that can help harmonize data collection and
analysis.
DATA FROM THE BUREAU OF LABOR STATISTICS
High-quality data are needed for policy makers at the federal, state,
and local levels and for leaders in the education sector to make informed
decisions. However, the allied health disciplines have a dearth of systematic
data collection and integration of that data, said Jones. Some data are avail-
able, but they have significant limitations.
Every 2 years the Bureau of Labor Statistics (BLS) issues 10-year work-
force projections. Data collection and analysis occur about 6 months before
the report comes out, and the last publication was in November 2009, with
15
OCR for page 16
16 ALLIED HEALTH WORKFORCE AND SERVICES
14
11.6
12
9.9
10
8.1
8
6.7
6
4.7
4 3.1
2
0
1958 1968 1978 1988 1998 2008
FIGURE 4-1 Percentage of total private-sector employment in private-sector health
care industries: 1958–2008.
SOURCE: BLS, 2009b.
figure 4-1.eps
a new publication planned for November 2011. The report provides antici-
pated job openings based on the creation of new jobs and projected retire-
ments and attrition. These projections are most useful for career guidance
and some long-term planning exercises, said Jones. They identify industries
expected to undergo growth, so that an individual can consider a career
in those industries or policy makers can invest in workforce development.
For example, as seen in Figure 4-1, the BLS data show health care occupa-
tions have grown rapidly as a percentage of total employment in the past:
from about 3 percent in 1958 to almost 12 percent today. Further, Table
4-1 shows that BLS projections also forecast strong growth in the future
for health care professionals.
Projections are also available for individual occupations (see Table 4-2),
but the data become less reliable at smaller scales for several reasons. First,
the model assumes full employment, but that assumption has not held for
the past several years and is unlikely to do so for the next few years at least.
According to a report from the Center on Education and the Workforce at
Georgetown University,
The recession that began in December of 2007 is already 30 months old,
but the U.S. economy will not recover its prerecession employment levels
for at least another 2 years. From there, it will take an additional 3 years
to make up for lost growth and create a job market strong enough to
employ both the casualties of the recession and the millions of new work-
ers who will stream into the workforce from schools across the country.
(Carnevale et al., 2010)
OCR for page 17
17
SUPPLY AND DEMAND
For example, even though the profession of nursing is projected to un-
dergo strong growth as the U.S. population ages, newly admitted resident
nurses have had a hard time finding jobs as the economy has struggled.
Also, the BLS data generally do not anticipate trends well within an
industry. For example, with the Patient Protection and Affordable Care Act
slated to provide insurance for millions of additional people, several major
questions arise: Will those people receive the majority of their care from
primary care physicians, nurse practitioners, physician assistants, or others?
What kinds of diagnostic testing will grow most strongly? Will accountable
care organizations or other kinds of institutions have increased control over
health care spending? Will projected growth in the number of physicians
increase the demand for people in allied health, as it has in the past? These
questions do not yet have answers, but those answers will have a powerful
effect on workforce trends within allied health.
The biggest problem with the BLS data, said Jones, is that they only
address demand, not supply. Matching demand to supply requires know-
ing the capacity for production in any given discipline. A cautionary tale
from pharmacy is a good example. The BLS data (see Table 4-2) show the
TABLE 4-1 U.S. Workforce Employment, 2008 and Projected 2018
Total job openings
Employment numbers due to growth and
(in thousands) net replacements,
Change 2008–2018
Occupation 2008 2018 (percentage) (in thousands)
Community and social 2,724 3,172 16.5 1,033
services occupations
Education, training, and 9,210 10,534 14.4 3,332
library occupations
Health care practitioners 7,491 9,091 21.4 3,139
and technical occupations
Health care support 3,982 5,130 28.8 1,595
occupations
Sales and related 15,903 16,883 6.2 5,713
occupations
Office and administrative 24,101 25,943 7.6 7,255
support occupations
Installation, maintenance, 5,798 6,238 7.6 1,586
and repair occupations
Production occupations 10,083 9,734 –3.5 2,156
SOURCE: BLS, 2009a.
OCR for page 18
18 ALLIED HEALTH WORKFORCE AND SERVICES
TABLE 4-2 U.S. Workforce Employment, 2008 and Projected 2018 by
Detailed Occupation
Total job openings
Employment numbers due to growth and
(in thousands) net replacements,
Change 2008–2018
Occupation 2008 2018 (percentage) (in thousands)
Physicians and surgeons 661 806 21.8 261
Pharmacists 270 316 17.0 106
Registered nurses 2,619 3,200 22.2 1,039
Occupational therapists 105 131 25.6 46
Physical therapists 186 242 30.3 79
Physician assistants 75 104 39.0 43
Speech-language 119 141 18.5 44
pathologists
Athletic trainers 16 22 37.0 12
Medical and clinical lab 172 193 11.9 53
technologists
Medical and clinical lab 156 181 16.1 55
technicians
Dental hygienists 174 237 36.1 98
Radiologic technologists 215 252 17.2 68
and technicians
Respiratory therapists 106 128 20.9 41
Home health aides 922 1,383 50.0 553
Medical assistants 484 648 33.9 218
SOURCE: BLS, 2009a.
demand for pharmacists growing by 17 percent from 2008 to 2018, with
106,000 new jobs over that period. For the past decade, pharmacy schools
have responded to these projections by increasing enrollments and opening
new programs. Now there is great concern about an overproduction of
pharmacists. Similar mismatches are occurring in other fields.
Data Needs
Jones cited several factors that need to be taken into account in estab-
lishing workforce development policies. First, many important data are
unavailable. What percentage of people trained in an area actually enter
OCR for page 19
19
SUPPLY AND DEMAND
that area, how long they stay in a profession, and how many people reenter
a profession after time away from it are all uncertain. The geographic dis-
tribution of workers is another issue, particularly as it affects care in under-
served areas. Finally, unforeseen policy or economic shifts can dramatically
and quickly affect both workforce supply and demand.
Workforce projections in allied health face particular challenges. Allied
health education is offered in almost every type of postsecondary educa-
tional institution. The professions that fall under the label of allied health
have different sizes and structures, different education requirements, and
different infrastructures for data collection. No one group has the respon-
sibility to provide the needed data, said Jones. “The federal government
does play a pivotal role in helping us to devise common ways to define the
data and then serves as a nonbiased source to integrate that data that we
collect, but this is something that we all have to share.”
ALLIED HEALTH WORKFORCE PLANNING
IN NORTH CAROLINA
In 1979 the North Carolina Health Professions Data System (HPDS)
began maintaining data files containing complete licensure data for a va-
riety of health professions (HPDS, 2011). A collaboration between the
University of North Carolina and the health professions licensing boards,
the HPDS seeks to provide timely, objective, and evidence-based analyses
to inform health workforce decisions. Data are provided voluntarily by the
boards—no legislation requires them to do so. “They do it because they
know it helps them and it helps the state,” said Fraher.
These data make it possible to do longitudinal and interprofessional
comparisons that can greatly improve statewide planning. For example, in
examining the data, Fraher found that the per capita population of physical
therapists in North Carolina grew almost fivefold from 1979 to 2009. The
population of physical therapy assistants has grown even faster, and both
grew faster than the supply of physicians, nurses, and pharmacists. How-
ever, the population of physical therapists grew most dramatically in the
areas of the state that do not have shortages of health care professionals.
Programs exist to get physicians and nurses into shortage areas, said Fraher,
but far less attention has been directed toward allied health professions.
The data also reveal that many allied health professions are less diverse
than the North Carolina population. “What are we doing to get under-
represented minorities into the allied health professions and build career
ladders?” Fraher asked.
The HPDS also collects demand-side data by tracking the number of
vacancies in online sources and newspapers. For example, data from 2010
(Kimball et al., 2011) show that occupational therapy assistants are in the
OCR for page 20
20 ALLIED HEALTH WORKFORCE AND SERVICES
highest demand relative to the size of the workforce. With 121 advertise-
ments and a workforce of about 900, about 13.4 vacancies exist for every
100 people in the workforce. Educators can use this information to set
enrollments in state programs, and workforce development boards can
use them to allocate efforts, Fraher said. Demand varies by location in the
state. About 30 percent of the allied health job vacancies in North Carolina
in 2010 were for physical therapists, but this number varies from almost
half in the southern portions of the state to about a quarter in the western
parts of the state.
The data collected by the HPDS reveal that allied health is “a job ma-
chine,” according to Fraher. As seen in Figure 4-2, employment in health
care and social assistance has steadily risen while manufacturing employ-
ment has fallen. “This is the graph that made the governor sit up straight
and say we need to be concentrating on health jobs.” Even in the recent
recession, Figure 4-3 shows that health care employment stayed fairly con-
stant, while employment in areas other than health care plummeted. Health
care has the potential to sustain local economies, particularly rural ones,
and is less vulnerable to outsourcing, Fraher said. Job growth in these fields
is also likely to continue given demographic changes, population growth,
and the expansion of insurance coverage.
The workforce development commission in North Carolina has cre-
ated an allied health regional skills partnership that includes community
colleges, local government, health care employers, and other regional stake -
900
Manufacturing
800
700 773.8
Employment (1000s)
553.7
600
500
393.7
400
448.6
Health Care and Social Assistance
300
200
100
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Year
FIGURE 4-2 Health care and social assistance employment vs. manufacturing em-
ployment, North Carolina, 1999–2009. 4-2.eps
figure
SOURCE: Reprinted with permission from Erin Fraher, North Carolina Health
Professions Data System.
OCR for page 21
21
SUPPLY AND DEMAND
480 3750
Health Care Employment 3700
Non-Health Care Employment (000)
470 3,712
Health Care Employment (000)
3650
467
460
3600
450 455 3550
3500
440
3450
430
3,435 3400
420
Non-Health Care 3350
Employment
410 3300
3250
400
Feb-08
Mar-08
Apr-08
May-08
Jun-08
Jul-08
Aug-08
Sep-08
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
Jan-08
Month-Year
FIGURE 4-3 Health care and non-health care employment during recession, North
Carolina.
SOURCE: Reprinted with permission from Erin Fraher, North Carolina Health
Professions Data System.
figure 4-3.eps
holders. The partnership addresses allied health workforce issues in the
region with a special focus on the sectors’ competitiveness and creating
employment and career advancement opportunities for unemployed and
dislocated workers. This is a great story, said Fraher, of “how you use data
to implement change.”
Data and Health Care Reform
As health care reform progresses, workforce planning will become
even more important, according to Fraher. Economic trends are of course
influential, but large-scale policy change is needed for the next generation
of workforce planning. In a new world of patient-centered medical homes
(PCMHs) and accountable care organizations (ACOs), the emphasis will
be on how care is delivered, not who delivers care.
Full implementation of the PCMH and ACO models will require shift-
ing workforce planning away from specific professional groups or em-
ployment sectors toward planning for the health service needs of defined
populations. Different models of care and configurations of skills will
OCR for page 22
22 ALLIED HEALTH WORKFORCE AND SERVICES
need to be evaluated for cost and quality. For example, one practice might
rely more heavily on medical assistants, while another uses more physical
therapy assistants than physical therapists. Much better and more data will
be needed on the effects of these differences on outcomes.
North Carolina has received a state health care workforce planning
grant from HRSA and has used it to assess the key health care services
provided by PCMHs, the number and types of professionals needed in
PCMHs, and how well supply matches the needs of the population. It also
is using the grant to identify the need for new programs, mechanisms to
retool the existing workforce, and the need for new professionals to meet
the needs of PCMHs.
Care in medical homes can be distinctive because of its reliance on
coordination, case management, and linking the health care system with
the community. But who does care coordination, Fraher asked. It could
be a nurse, a social worker, a medical assistant, or another health care
professional. Similarly, patient education can be done by medical assis-
tants, registered nurses, primary care physicians, or others. “Let’s open the
patient-centered medical home box and understand who is in there and
what they’re doing . . . and then think about what that means for new
programs,” Fraher said. Change will often require retooling the existing
workforce rather than relying on new graduates and being open to new
health professions that emerge as a result of change.
Lessons Learned in North Carolina
Fraher pointed to several lessons learned from experiences in North
Carolina. First, we plan, she said. Having better information enables em-
ployers, educators, practitioners, and students to make better decisions. For
example, Fraher noted that workforce planning saved the state $80 million
when it decided not to open a pharmacy school because data showed that it
did not need another pharmacy school. Instead, the data pointed to serious
oral health disparities in the eastern part of the state, and eastern North
Carolina now has an innovative model of dental education. “We actively
engage in using our data for workforce planning.” An inventory of exist-
ing datasets could show what data are not collected that need to be, what
the strengths and limitations of existing data are, and what the barriers to
getting data are. Also, if a minimum dataset is defined, it should expand to
cover all valid health professions, said Fraher.
Another lesson learned is to cultivate a role for professional associa-
tions and licensure bodies. The licensure bodies in North Carolina have
been “fantastic,” said Fraher. “They are as actively involved in understand-
ing health workforce planning in the state as we are.”
The balance between the state and federal roles is still in flux. What is
OCR for page 23
23
SUPPLY AND DEMAND
the national role in health workforce planning, what is the state role, and
how can the two best work together?
National data comparable to the North Carolina data are not yet avail-
able. National data would benefit North Carolina as well as other states,
because then state data could be compared with numbers in other states and
with data for the nation as a whole. One impediment is that different states
and the federal government have different ways of collecting and analyz-
ing data. “Let’s get together and learn how to speak the same language,”
Fraher stated.
Finally, continued investments are needed to build and maintain these
datasets, and states will need technical assistance to get them up and run-
ning. “Be inventive,” said Fraher. “It’s not just federal resources; there is
foundation funding and other funding.”
A UNIFORM HEALTH PROFESSIONS DATASET
Health workforce data serve several important uses, said Nooney. First,
they make it possible to understand trends in workforce supply, demand,
distribution, and shortage. “You have to know where you’ve been and
what types of conditions occur alongside shortages to be able to predict
when this is going to occur again,” Nooney said. Second, workforce data
collected across time, place, and profession enable benchmarking against
other professions, geographic areas, and baseline levels. “We have lots of
workforce data, but one of the problems is it is all a little bit different from
place to place and profession to profession. That hampers our ability to
make these comparisons.” Third, data are a needed input for projections of
supply and demand. Good projections provide detailed information about,
for example, career transitions, the aging of the workforce, and when work-
ers tend to retire. Without this information, it is difficult or impossible to
project workforce supply in a particular area. Fourth, workforce data guide
the development and evaluation of policies and programs to enhance the
health workforce. Good policies are data driven. When something is going
wrong, the data indicate ways to fix the problem and monitor progress
toward a solution. “They allow course corrections through policies and
programs,” said Nooney.
Sources and Limitations of Workforce Data
Many different entities collect workforce data in the health professions,
and data are plentiful, but the quality of the data ranges widely. Many
professional associations collect supply-side information on their work-
force during membership renewal and at conferences. Many professional
associations also attempt to survey all licensed professionals within an
OCR for page 24
24 ALLIED HEALTH WORKFORCE AND SERVICES
area, but because they generally do not have the ability to mandate comple-
tion of the surveys, the data are incomplete. Regulatory and certification
organizations, including state licensure boards and national certification
and credentialing organizations, collect data during the registration and
licensing processes. In this case, they are able to reach all of the licensed
professionals in an area every several years. “That’s a great opportunity to
collect information,” said Nooney. State workforce planning agencies, such
as the HPDS in North Carolina, collect workforce data. Many researchers
also collect workforce data, though their samples are often small and their
topics narrow. However, these data can be useful for digging deeply into
some of the complex questions that surround the workforce. Finally, the
federal government collects data, both through federal-state collaboratives
and through primary data collection. For example, HRSA has supported
the National Sample Survey of Registered Nurses quadrennially since 1977
(HRSA, 2011b).
Despite all these sources of data, the information available is not suf-
ficient to meet many policy objectives, Nooney said. As Fraher observed,
the wide variation in approach is a major problem. The items in surveys,
the wording or response options, the populations being sampled, and other
factors vary from source to source. “This is problematic because we can’t
put all of this together and make the comparisons that we need,” said
Nooney. “Differences in data collection hamper comparisons across profes-
sions, area, and time.”
A Minimum Dataset
The purpose of the minimum dataset project at HRSA is to standardize
data collection to improve workforce planning and policy development. As
a first step, HRSA is focusing on supply data, with plans to apply lessons
learned in that area to demand data and education program capacity and
output. It also is collecting data initially for a limited number of health
professions: physicians, nurses (including advanced practice nurses), physi-
cian assistants, dentists and dental hygienists, pharmacists, and physical
therapists. These professions are some of the largest in health care and also
reflect the priorities of HRSA, which is focused on primary care and health
profession shortage areas.
Datasets will be harmonized through standardized questionnaires or
instruments. A meeting of researchers was convened to discuss which items
are essential, which are not essential, and the purposes of data collection.
Items for a minimum dataset have been drafted, and at the time of the
workshop they were being circulated for internal review and revision. The
next step is to convene stakeholder meetings to gather feedback from the
community about the items and about implementation. Documentation and
OCR for page 25
25
SUPPLY AND DEMAND
guidelines will be drafted to help in the collection of data, and outreach and
technical assistance will promote implementation.
The broad areas in the minimum dataset include education and training
(e.g., degrees earned and types of training and certification); basic demo-
graphic data (e.g., age, gender, and race); and practice, activity, and employ-
ment information (e.g., numbers of hours worked, activities conducted, and
where those activities are conducted).
Nooney emphasized the word minimum. HRSA is not trying to col-
lect detailed data for each profession. It is seeking to develop a core set of
essential items that can be implemented with limited resources. “We are
trying to keep it small and focus on standardizing a small subset of items
that we can’t live without.” HRSA also will be building on the many enti-
ties that have well-developed data collection infrastructures. For example,
professional associations and state licensure boards are in a unique position
to support this endeavor because they collect data every time a licensed
professional reregisters. Licensed professions such as medicine and nursing
have available sources of data, but allied health is a bigger challenge since
it is populated with many unlicensed professions. Also, some allied health
professions have a lower rate of professional identity or membership in
professional associations, which reduces the potential for data collection.
And allied health professionals tend to practice in a wide variety of settings,
so trying to reach them at their place of employment or through employers
is a challenge. HRSA hopes to work out some of these problems before
expanding to many of the allied health professions.
The benefits of a minimum dataset in the allied health professions will
be similar to the benefits for medicine, nursing, and other professions, said
Nooney. It will support the ability to assess trends in supply, distribution,
and practice patterns; enable more accurate projections; guide the develop-
ment of programs and policies; and improve understanding of workforce
aging and retirement patterns. In fact, concluded Nooney, data for the allied
health professions will be even more useful than in other areas because so
little data are available today.
DISCUSSION
During the discussion period, the moderator of the session on data
needs, Edward Salsberg, director of the National Center for Health Work-
force Analysis, said that HRSA was open to talking with other allied health
professions, in addition to physical therapy, about the minimum dataset.
“One of the challenges, as you’ve seen from this morning’s discussion, is
who we should sit with if we want to talk about allied health professions
as a group.”
He also discussed possible ways to motivate organizations and states to
OCR for page 26
26 ALLIED HEALTH WORKFORCE AND SERVICES
collect data. One approach is simply to emphasize that it is in an organiza-
tion’s or state’s interest to do so. Another argument is that better data can
help with the credentialing process.
He mentioned that HRSA is working with the BLS on demand-side
issues. One complication is that the Standard Occupational Classification
(SOC) is only changed once every 10 years, and the most recent change
was in 2010. Because of the lead time involved in making changes, people
who want to add an allied health profession to the next release of the SOC
should start working with HRSA and BLS now.
Jones emphasized that the allied health professions cannot expect
HRSA to collect all of the data that are needed. States, professional orga-
nizations, and educational institutions all need to collect data in a useful
format and combine their efforts. These organizations also have much to
gain from participating in this effort.
A workshop participant observed that standards, licensing, and cre-
dentialing requirements (e.g., requirements for higher educational levels)
are often used to control the number of people in a workforce, and Jones
agreed, saying that economic realities are inevitably a factor. But he also
noted that health care reform is seeking to change some of these forces.
Some activities carried out only by physicians in the past may move into
the allied health professions. Activities such as coordinating chronic disease
management could be handled in many different ways, and health care
reform will influence the decisions that are made.
Fraher brought up the divide between advanced educational require-
ments and the activities actually performed in some allied health fields. For
example, physical therapy contains two groups of practitioners: a more
advanced group for whom higher educational levels are appropriate, and a
more assistive group. Also, high educational levels can contribute to a lack
of diversity and geographic disparities, she said. For example, community
colleges tend to pull from their local communities and produce graduates
who go to work in their local communities, which results in a more diverse
and distributed workforce. Nursing deals with many of the same kinds of
issues as allied health and could provide a model for allied health fields,
she said.
Nooney observed that demand projections depend heavily on the age,
size, and shape of the population. Also, surveying employers is a way to
get demand-side information not available in other ways. “Employers see
what’s happening on the ground,” she said. “They have vacancies or they
don’t. They have trouble recruiting or they don’t. They have plans to ex-
pand their practice or their facility or they don’t.”
In response to a question about whether the professionals delivering
care have the body of knowledge, accreditation, or certification needed to
do so, Fraher said that much better data are needed on the outcomes of
OCR for page 27
27
SUPPLY AND DEMAND
using assistive personnel. “What are the implications for cost and quality
of substituting an assistive person for someone else—we don’t know.” Cer-
tification limits supply, but better evidence is needed on skill mix configura-
tions and what they mean for cost and quality.
Salsberg responded that a challenge in the workforce planning com-
munity is to understand both short- and long-term trends. In the recent
recession, the job market was soft even for nurses and allied health profes-
sionals, but that does not say much about what the job market will be like
10 years from now. “It is critical that we do the analysis . . . so we can
advise the community.” A focus on the short term can lead to overproduc-
tion and temporary surpluses followed by underproduction and shortages.
“Getting better data and looking at the long-term needs is going to be
critical for the future.”
OCR for page 28
