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A flied HEALT Scry ices Avoiding Crises Committee to Study the Role of Allied Health Personnel INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1989

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal gov- ernment and its own initiative in identifying issues of medical care, research, and education. This project was supported by the Health Resources and Services Administration, HRSA Contract No. 240-86-0066. Library of Congress Cataloging-in-Publication Data Allied health services: avoiding crises / Committee to Study the Role of Allied Health Personnel, Institute of Medicine. p. cm. Bibliography: p. Includes index. ISBN 0-309-03929-0.ISBN 0-309-03896-0 (pbk.) 1. Medical policy United States. 2. Allied health personnel- Government policy United States. 3. Paramedical education Government policy United States. I. Institute of Medicine (U.S.). Committee to Study the Role of Allied Health Personnel. RA395.A3A479 1988 362.1'7 dcl9 Printed in the United States of America 88-37922 CIP

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Study Staff KARL D. YORDY, Director, Division of Health Care Services MICHAEL L. MILLMAN, Study Director SUNNY G. YODER, Associate Director JESSICA TOWNSEND, Research Associate MARYANNE P. KEENAN, Research Associate CAROL C. McKETTY, Research Associate DELORES H. SUTTON, Secretary WALLACE K. WATERFALL, Editor, Institute of Medicine Consultants NAOMI BOOKER RUTH BROWN EUGENIA CARPENTER NURIT ERGER HAROLD GOLDSTEIN OLIVE M. KIMBALL EDMUND I. McTERNAN RICHARD MORRISON BILL WALTON i' Rev

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Preface THIS REPORT IS THE RESULT of an 18-month study by the Committee to Study the Role of Allied Health Personnel of the Institute of Med- icine to explore policy issues that surround the roles of allied health per- sonnel. It was prompted by a congressional mandate contained in Public Law 99-129, the Health Professions Training Act of 1985 (Appendix A) and implemented through a contract with the Health Resources and Ser- vices Administration of the Department of Health and Human Services. The study is the first major independent examination of the diverse set of health care occupations that often fall under the umbrella term allied health. STUDY BACKGROUND Although some allied health fields such as dietetics date back to the nineteenth century, it was the federal health professions legislation of the 1960s that gave life to the concept of a collectivity now known as allied health personnel. Despite the withdrawal of most direct federal support for allied health education in the early 1980s, allied health leaders convinced Congress that such a large part of the health care work force (estimated at from 1 to almost 4 million people) should not continue to go unmonitored and un- studied, especially when so much about the health care system is under- going sweeping change. Some factors in this reshaping include increasing pressure from both the public and private sectors to curtail costs; the introduction of new, sophisticated health technologies; growing numbers of elderly patients; increasing attention to individuals with chronic disa- v

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V1 PREFACE bilities; and drastic developments in disease, such as the acquired immune deficiency syndrome (AIDS) epidemic. How the health care system adapts to these pressures depends in large part on whether workers with the requisite education are available at the right place and time. Consequently, a careful assessment of future person- nel needs has never been more important than it is now. Making sound policy decisions about education, regulation, and other matters that affect the demand for and supply of allied health personnel is difficult, however, in part because allied health personnel have been among the least studied elements of the health care system. In response to this deficiency, Congress in 1985 mandated this national study. INTERPRETATION OF THE CONGRESSIONAL CHARGE Congress posed five tasks for the study: 1. Assess the role of allied health personnel in health care delivery. 2. Identify projected needs, availability, and requirements of various types of health care delivery systems for each type of allied health personnel. 3. Investigate current practices under which each type of allied health personnel obtains licenses, credentials, and accreditation. 4. Assess changes in programs and curricula for the education of allied health personnel and in the delivery of services by such personnel that are necessary to meet the needs and requirements identified pursuant to item 2. 5. Assess the role of federal, state, and local governments, educational institutions, and health care facilities in meeting the needs and requirements identified pursuant to item 2. These inquiries were not raised in the specific context of existing or proposed federal legislation but rather from a broader concern that a large body of health care workers had received insufficient attention in relation to their importance in future health care. In effect, Congress asked for information about this major component of the health work force to de- termine whether corrective action was needed, and if so, where responsi- bility for such action rested. The study committee was directed to assess the role of allied health personnel in the delivery of health care. It has interpreted this charge as a request for better information about the ways in which allied health practitioners are deployed, their functions, their relationships with other health care practitioners, and the settings in which they work. In addition, the committee has interpreted the charge as a need to elucidate the various factors and forces education and training, employer requirements, third-

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PREFACE ~ V11 party payer policies and the regulatory apparatus, to name several of importance that shape that role. The second item in the congressional charge, in effect, asks the committee to provide its best judgment as to whether the needed future services of allied health practitioners will be available. This task in turn raises questions about the way the allied health labor market operates and whether market adjustments can be expected to take place (for instance, salary increases, if the demand for personnel should outpace supply) before service dislo- cation or quality erosion occurs. Although much of the report addresses the likely future market demand for allied health workers, the committee has not overlooked the fact that there may be some important service needs that are not being met now. Long-term care is a current example of the way a lack of good jobs and reimbursement can undermine the nation's ability to supply certain basic services. In the charge's third item, Congress requests an examination of licensure and other forms of credentialing in allied health fields. The committee believes this request expresses concern about the imbalance between the costs and inefficiencies of regulation on one hand and the need to protect consumers from poor quality care on the other. To make the desired adjustments, we need a better understanding of the current situation, the contribution of regulation to quality, and the diverse costs of regulation. The fourth item of the congressional chargean examination of edu- cation programs and curriculaarises from concerns about whether allied health education is now and can remain in step with the changing nature of health services. The committee also interpreted this segment of the charge to include a consideration of whether allied health education pro- grams are likely to be able to compete for higher education resources and for students interested in pursuing technically oriented careers. The final congressional request is for an assessment of the abilities of major legislative, educational, and health care entities to make the necessary adjustments that will ensure that allied health personnel can fulfill their potential in the health care delivery system of the future. Some of the questions for which the committee sought answers in this regard included the following: If intervention is needed, who has the final responsibility and leverage to act, and how can they know when and how to intervene? STUDY APPROACH To address the questions posed by Congress, the committee and study staff solicited information from a broad array of organizations, including the allied health professional associations, state regulatory agencies, and higher education coordinating bodies, and federal agencies such as the

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~ V111 PREFACE Bureau of Health Professions and the Bureau of Labor Statistics. In ad- dition, the committee held two workshops with invited experts and a public meeting on the regulation of allied health personnel. The first of the two workshops concerned the future demand for allied health workers; the second concerned education and the supply of workers. (Appendix B is a list of the participants at each of these meetings.) Study staff and committee members also visited health care provider institutions, including several long-term care facilities, health maintenance organizations, and a multi- hosoital system. lathe committee has not collected primary data but instead has used existing data from a variety of sources to focus on important issues. These issues were explored primarily through an examination of 10 allied health fields. Individually, these fields reflect different facets of allied health oc- cupations; collectively, they reveal some common threads in the way all allied health fields can respond to the challenge of a changing health care system. This study is a first step toward addressing a neglected topic in health care policy. The committee did not have the benefits of either large-scale sample surveys or an extensive body of empirical literature. Recognizing that a rich data base may not be in the immediate future for allied health, the committee has suggested strategies for enhancing existing data to im- prove the grounds on which decision makers act. Allied health is an ill-defined term. Because there is no consensus about which occupations constitute allied health, and because the more compre- hensive definitions encompass so many fields that study is impracticable, the committee settled on a set of fields that exclude some occupations that readers might expect to find. Among those excluded are nurses, nurse practitioners, midwives, physician assistants, pharmacists, and social work- ers and mental health counselors. Guiding the committee's selection of study fields was the federal health professions legislation and the need to cast light on large but relatively unstudied occupations. MAJOR STUDY THEMES The following report is intended for a wide audience: allied health professional organizations, administrators at educational institutions, state regulatory and licensing bodies, employers of allied health personnel, and policymakers at both the state and federal levels. Although the study's findings are most often based on national data and trends, the analysis is intended for use by all "actors" in the field who are looking to the future, including those at the local level the college administrator considering whether to offer allied health programs, the legislator voting on a licensure

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PREFACE 1X law, the home care agency administrator setting salary levels for employees, and the therapist considering whether to establish an independent practice. The reader may wish to be alert for several themes that have guided the committee in determining areas for its recommendations. These themes, which were derived from the study activities and are interwoven throughout the report, include the following: allied health personnel as an under-recognized but important human resource; the need for data and research to provide the basis for more effective use of allied health personnel; the need for health care and educational institutions to assist each other in adjusting to new realities in the way services will be delivered in the future; ~ the fragility of some of the education programs that provide new entrants into the allied health fields; the importance of competitive levels of compensation in a labor market in which individuals with technical- and service-oriented skills will be at a premium; and the need to balance quality concerns with those of cost, flexibility, and employment opportunity in the regulatory policy arena. ORGANIZATION OF THE REPORT Chapter 1 introduces the subject of the study, allied health occupations, and briefly traces the evolution of 10 fields. Chapter 2 examines various data sources and discusses ways to forecast the demand for and supply of allied health personnel. Chapter 3 looks at such forces as demography, disease patterns, the structure of the health care delivery system, and wom- en's study choices, all of which affect allied health personnel demand and supply. Chapter 4 reviews national projections of the demand for allied health workers through the year 2000 and Presents the committee's as- sessment of that demand and its own assumptions and projections of supply. In Chapter 5 the committee addresses the contribution of educational output to future supply. Recommendations are offered to increase the recruitment of students, including minority students, into allied health education programs and to improve the capacity of educational institutions to support such programs. Chapter 5 also discusses the levels and content of education needed to prepare practitioners for the future work force In presenting the employer's perspective in Chapter C 1 reviews some of the available options for correcting and adapting to per- ~ the committee

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x PREFACE sonnet supply imbalances and charts a role for health care administrators in enhancing the size and effectiveness of the allied health work force. Chapter 7 describes the various mechanisms of control of allied health personnel, focusing principally on the problems state legislators face in making decisions about licensure and other forms of occupational regu- lation. The chapter emphasizes the need for flexibility in the functions of allied health personnel. Finally, Chapter 8 takes up long-term care and the needs it poses for allied health personnel. WILLIAM RICHARDSON Chairman

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Acknowledgments THE COMMITTEE G~TEFULLY acknowledges the contributions of many people and organizations who provided assistance and information to this study. Chief among the organizations are the allied health professional associations themselves. Despite apprehensions from time to time about what conclusions and recommendations the committee might produce, these organizations generously rose to the challenge of providing the in- formation the committee requested. The committee solicited input from a wide-ranging set of allied health associations and wishes to thank each of them. Special acknowledgments, however, are in order for those associa- tions representing the 10 fields studied in-depth, as well as the American 1 0 Society of Allied Health Professions and the National Society of Allied Health Professions. The committee was also aided by Dr. Gerry Kaminski, Dean of Cincinnati Technical College, who provided us with information from the organization of two-year college allied health deans on allied health programs in community colleges. Several government agencies provided critical assistance in the use of federal data systems. Our deepest thanks go to Ann Kahl and her staff, Sandy Gamliel, Steven Tise, and William Austin, who spent considerable time with the staff discussing the Bureau of Labor Statistics (BLS) meth- odology and their work on specific allied health fields. Alan Eck, also of the BLS, generously offered his expertise in the areas of supply and oc- cupational mobility. Debra Gerald of the U.S. Department of Education was extremely helpful in providing the committee with higher education projections. Numerous individuals in the central office and facilities of the Veterans Administration were willing to describe their experiences in re- X1

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~ X11 ACKNOWLEDGMENTS cruising, retaining, and educating allied health staff. Above all, we wish to thank our sponsors, the Bureau of Health Professions, Health Resources and Services Administration. Tullio Albertini, the study project officer, and other staff members were eager to meet the committee's needs for guidance and information throughout the study. We also wish to acknowledge a number of institutions who welcomed committee members and staff, allowing us to tour their facilities and speak to allied health personnel in the workplace. These institutions include the Sisters of Mercy Health Corporation, Harvard Community Health Plan, Rancho Los Amigos Medical Center, Beverly Manor Convalescent Hospital, On Lok Senior Health Services, Garden Sullivan Hospital, VA Medical Center Palo Alto, Durham County General Hospital, Beverly Health Care Center, Tarboro, N.C., and the Berry Hill Nursing Home. Our thanks also go to I. Warren Perry, Alexander McMahon, and John DiBiaggio for attending committee workshops and providing advice to committee and staff. Finally, we wish to thank all those individuals (listed in Appendix B) who participated in our public hearings and workshops. WILLIAM RICHARDSON Chairman