Allied Health Services: Avoiding Crises (1989)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 159 5 The Role of Educational Policy in Influencing Supply IF NO STEPS ARE TAKEN to bolster the future supply of personnel in several allied health fields, health care institutions will be hampered in meeting the public's demand for services. These steps will require coordinated actions by educators and employers, encouraged by modest but strategic federal, state, and private programs. Many of the recommendations in this and the following chapter are directed toward educators, employers, and the allied health professions themselves. Although the committee believes its recommendations will be beneficial to those parties, it looks to public intervention to stimulate and amplify their implementation. This chapter is divided into three sections. The first deals with policies to influence the decisions of persons choosing careers. The second discusses the role of educational institutions in maintaining or expanding enrollments. The third addresses concerns about the preparedness of the future allied health work force. THE ALLIED HEALTH STUDENT APPLICANT POOL For most fields the available trend data on allied health programs and graduations do not signal an imminent crisis requiring dramatic public intervention. Looking to the future, however, the committee is deeply concerned that the weak infrastructure of allied health education may compromise the system's ability to maintain enrollments, let alone increase the supply of personnel in fields in which employment demand is high. A key to the viability of allied health education is its capacity to maintain its 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 160 share of qualified students from the traditional college-age applicant pool while tapping into less traditional pools of students, particularly minority students. For a number of years, allied health deans and program directors have expressed concern about the declining number of applicants to their programs and the implications of this decline for the academic quality of the student body. Reportedly, spaces in many programs are going unfilled, and this lack of student interest is jeopardizing the survival of academic programs. Comprehensive data collection concerning applicants to allied health programs is not currently being done. However, CAHEA annually surveys program directors in several allied health fields about whether applications to their programs are increasing, decreasing, or remaining stable. In its 1987 survey, program directors in 13 of 22 fields reported decreases in the number of applicants (CAHEA, 1988). The clinical laboratory fields in particular were experiencing distress. For example, almost two-thirds of the medical technology program directors reported decreases in applicants in 1987. Of the 116 programs that voluntarily withdrew from CAHEA accreditation between 1983 and 1987, 36 attributed their decisions to a declining applicant pool. Unpublished survey data from the American Society of Allied Health Professions suggest that only physical therapy has a large applicant pool to draw upon, with about five applicants per academic space. Other fields such as dietetics, medical technology, radiologic technology, and medical record administration average, only slightly more applicants than needed to fill their classes. A recent (1987) survey of the College of Health Deans, an organization composed of allied health administrative units in 20 universities without medical centers from 17 states, revealed that only 3 out of 17 respondents reported that all of their professional classes were filled. Although clinical laboratory programs were those most frequently cited as having excess capacity, many other fields also reported unfilled classes. Although the current level of applications worries academic administrators, they are even more concerned about the future because of the predicted decline in the college-age cohort of the population, an issue discussed in Chapter 3. This decrease suggests that in the future there may be even greater competition among schools for technically oriented students than there is today. Information from annual surveys of college freshmen on changing occupational preferences shows a slow but steady decline (from 3.3 percent to 1.1 percent) between 1977 and 1985 in women's interest in careers in laboratory technology and dental hygiene, dietetics and home economy (from 1.1 percent to 0.4 percent), and health technology (from 3.7 percent to 1.8 percent). Women's interest in the category headed "therapist" has remained relatively stable over the period; men have exhibited 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 161 gradually increasing interest over the years (Cooperative Institutional Research Program, 1987). Academic administrators are also concerned that, with fewer applicants from which to select, the quality of students will decline. Thus far, except for the areas of clinical laboratory sciences and radiography, no decrease in student quality seems to be evident to program directors, as measured by the CAHEA survey. More objective evidence for assessing quality changes, such as grade point averages or test scores during students' first year of professional course work, is not routinely collected. The American College Testing (ACT) Program test scores of high school juniors who intend to major in allied health fields do not bear out a shift in quality (Table 5-1), although the downward trend in dental hygiene may deserve some attention. Not every allied health field has experienced an applicant deficit, as evidenced by what has occurred in the physical therapy field. Despite a rapid increase in the establishment of physical therapy programs, most directors report that they still have more than an adequate supply of applicants and can limit enrollment to those with high grade point averages. It is not unusual to find physical therapy programs with application-to-acceptance ratios of 10 to 1. In addition to physical therapy, a few of the newer professions such as perfusion and diagnostic medical sonography are also in great demand, with about 60 percent of program directors experiencing application increases (CAHEA, 1988). Because they are fewer in number and smaller in size, it is difficult to equate the success of programs like perfusion, for example, with programs in physical therapy. Nonetheless, characteristics of perfusion programs are worth noting. Some of the students are often drawn from other disciplines 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 162 (respiratory therapy and critical care nursing, for example) and therefore have had some exposure to the new field. Employment opportunities abound, and not all graduating students enter the clinical field because other attractive opportunities are often available. For example, manufacturers and biomedical engineering laboratories hire some perfusionists; some enter medical school and others choose teaching. Although perfusion is a high-stress profession, it is also a relatively well-paid one. The average salary for a graduating student is $35,000, but highly qualified and experienced perfusionists may earn close to $100,000. Although they are not known to the general public, perfusionists are respected in the allied health world for their success in garnering earnings and their relative independence (Brown, 1987). Why do some programs fare better than others in attracting students? Some reasons come readily to mind. Undoubtedly, the positive economic outlook for physical therapy—rising salaries, growing autonomy, and high levels of demand for graduates—has affected student thinking. Also, in comparison with such fields as clinical laboratory technology, physical therapy has greater public visibility and more patient contact. There may be lessons to be learned from schools of social work, which have succeeded in increasing their applicant pool from 2 applicants per opening in 1983 to 3.5 applicants per opening today. Social work is considered to be closely related to (if not directly under the umbrella of) allied health. Deans of schools of social work attribute the revitalization of interest in social work careers to a wide variety of social and economic factors, including the following: • optimism about the status of social welfare programs in the post- Reagan era; • a surge (although not as dramatic as during the 1960s) in the sense of social commitment among students; • occupational outlook projections of higher-than-average growth in demand; • growth of independent practices and third-party payment; • adoption by some schools of "business-like" approaches to marketing and recruiting students; and • salaries that, while not high initially, averaged about $27,800 in 1986-1987 (Health Professions Report, 1988). Visibility and comparatively high pay are elements that contribute to the attractiveness of a field, and these in turn contribute to the success of schools in obtaining high application rates. Some fields that are viewed by the allied health community as being attractive and offering well-paying careers nonetheless do poorly in attracting students because they lack visibility. For example, occupational therapy shares many of the attributes of physical 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 163 therapy, but its role in health care is not well known. Medical record administrators can earn over $50,000 per year and advance to hospital executive positions, but that field, too, is little known to the public. Some allied health occupations (e.g., medical technology and radiography) do not offer particularly good economic rewards but seek to attract scientifically oriented students to work in potentially hazardous environments in which they may be exposed to contaminated body fluids or radiation. Moreover, although laboratory and radiography employment prospects may be rebounding after PPS cutbacks, the atmosphere of job insecurity may still be influencing students' perceptions about those fields. Student Recruitment Many of the social factors that influence career choice are beyond the control of health care institutions or academics. The economic attractiveness of careers and their work environments are largely in the hands of employers (a topic that is addressed in Chapter 6) and those who make reimbursement decisions. There are a number of techniques that schools have used to attract students. Among them are the use of professional recruiters, giving faculty release time to visit high school counselors and students, the distribution of videotapes about the school, and undertaking national promotions (e.g., Lab Week, fostered by the American Society for Medical Technology). Unfortunately, such efforts to influence students' career choices toward an allied health field have not been systematically documented or evaluated. Many psychological and social theories of career choice and career development have emerged over the years to explain how individual career development unfolds over the life span. These theories suggest the difficulties of intervening in a complex process. Career development is shaped by an interplay of psychological attributes, knowledge about training requirements, educational and occupational opportunities, genetic and childhood influences, evolving personalities, and patterns of traits that individuals express cognitively and psychologically in their choice behavior. Research related to career development finds that, like all human behavior, it is a highly complex process and is part of the total fabric of personality (Lent et al., 1986). Most of the existing approaches to career development are based on limited samples of relatively privileged persons. The samples typically have been composed of men rather than of women, and the approaches to career development in general have been addressed to persons in the middle range of socioeconomic characteristics. Consequently, these approaches tend to emphasize the continuous and progressive aspects of career development that are possible primarily for persons who are rela 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 164 tively free to choose any career and for whom both psychological and economic resources are available. Such criteria do not necessarily fit women and minorities (Fitzgerald and Crites, 1980). The impact of several variables (including parental socioeconomic status [SES], academic achievement, and sex) on both selection and persistence in career choice has been investigated in an attempt to determine who is being recruited into professions in general. These variables were used to analyze responses from the U.S. Department of Education's 1972 National Longitudinal Study and recent follow-up surveys. Results showed that children of high-SES parents were four times more likely than children of low-SES parents to engage in professional study at the baccalaureate level and six times more likely to participate in or complete professional training at the graduate level. The SES level of parents did not have as much effect on the aspirations of children, however; children of high-SES families were only twice as likely to wish for a professional career as their contemporaries from low-SES families. Researchers have concluded that the idea of substantial social and economic mobility in the United States has been exaggerated and is difficult to achieve. Only 2 percent of young people from low-SES homes were in graduate-level professional programs 7 years after high school, despite large federal student aid programs and numerous corporate and foundation programs to stimulate opportunities in the professions (Miller, 1986). In general, the career choice literature does not provide detailed guidance for recruitment efforts. Yet several implications for specific planning interventions can be seen. • The concepts that people are only economic animals and that work is chosen only for the livelihood it offers are too simplistic. Work also provides a means for meeting the needs of social interaction, dignity, self-esteem, self-identification, and other forms of psychological gratification. • Personal, educational, occupational, or career maturation comprises complex learning processes that begin in early childhood and continue throughout life. • Choice occurs not at a point in time but in relation to antecedent experiences and future alternatives. • Career information must include not only objective factors such as earning possibilities, training requirements, and numbers of positions available but the social and psychological aspects of careers as well. • Career choice is frequently a compromise between the attractiveness of an alternative, the likelihood of attaining it, and the costs of attaining it (Herr and Cramer, 1984). In sum, the literature on career choice is suggestive rather than prescriptive for recruitment tactics. Long-range efforts must take into account 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 165 the need to make individuals aware of careers at an early stage. If women continue to predominate in many of the allied health fields, we must learn more about the dynamics of their career choice behavior. Successful student recruitment efforts generally depend on positive market signals emanating from the world of work. In the next chapter the committee discusses actions that employers must take to improve the circumstances of allied health personnel in work settings in which the perceptions of unsatisfactory careers accurately reflect reality. However, to the extent that potential students incorrectly believe that a career is unsatisfactory, the problem may require improved communication. Local consortia of professional association members, employer representatives, and educators should be formed to devise recruitment strategies based on community needs, characteristics, and resources. These consortia should target nontraditional audiences, tailoring the message and method of communication to each. A marketing plan geared to attracting newly unemployed workers from a local industry, for example, should not be the same as one that seeks to attract displaced homemakers or handicapped high school students. The demand for technically oriented people is growing in many sectors of the economy. One study predicts that The jobs that will be created between 1987 and 2000 will be substantially different from those in existence today. A number of jobs in the least-skilled job classes will disappear, while high-skilled professions will grow rapidly. Overall the skill mix of the economy will be moving rapidly upscale, with most new jobs demanding more education and higher levels of language, math and reasoning skills. (Hudson Institute, 1987) More specifically, more than half of the new jobs created between 1984 and the year 2000 will need some high school education. Nearly a third will require a college degree; today, only 22 percent of occupations require a college degree (Hudson Institute, 1987). The health care industry is not the only industry that is beginning to understand that one of the challenges of the future will be to position themselves favorably in the competition for the supply of educated, technically able workers. For some allied health fields, there are already indications that potential practitioners are being lost to other professions. It is clear that educators, employers, and the professional associations must act if they want to maintain or increase their share of the work force. The process of change is necessarily interactive. If employers succeed in making allied health employment more attractive, educational institutions will experience increases in the size and quality of the applicant pool. Yet, circularly, the extent to which employers are able to alter the conditions of employment depends in part on the education that workers have received. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 166 The committee recommends that educational institutions, in close collaboration with employers and professional associations, organize for the recruitment of students. They should seek persons from less traditional applicant pools—minorities, older students, career changers, those already employed in health care, men (for fields in which they are under- represented), and individuals with handicapping conditions . Minorities Two major societal problems underlie concerns about minority participation in allied health careers, leading the committee to devote special attention to this issue. First, as several recent public policy documents have stated, minority populations in the United States have comparatively poor health statuses and use fewer health care resources relative to their needs (U.S. Department of Health and Human Services, 1985). Although a causal relationship between the supply of minority practitioners and improved minority health care and health status is difficult to validate, minority health care workers are more likely to work in geographic areas and at delivery sites that serve minority and other disadvantaged patients. Officials interviewed at three inner-city hospitals, including two public hospitals, said that minorities are at least 50 percent of their total allied health work force. Moreover, data extracted from facility records show that this pattern is relatively uniform across such different fields as clinical laboratory technology, physical and occupational therapy, dietetics, and medical records (Booker, 1987). Second, there is a lack of parity throughout American society between whites and nonwhites in professional positions. To the extent that the allied health fields can provide improved career opportunities for minorities, a double benefit will occur: education programs will be better able to maintain enrollments, and personnel shortages may be alleviated in underserved geographic areas and institutions that serve poor minority populations. To supplement a review of the literature on the representation of minorities in allied health fields, the committee conducted extensive interviews with deans and faculty of 10 schools active in the National Society for Allied Health (an organization committed to increasing the participation of black and other disadvantaged minorities in allied health practice, education, and administration). Other schools were added in an attempt to broaden the information base. A school known to have a predominantly Hispanic student body and structured activities to recruit Hispanics to allied health programs was selected, as was a school in an area with a large American Indian population. Finally, a nonminority school in the South was added because it boasts the largest number of allied health programs on a single campus and has been actively involved in minority allied health recruitment 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 167 and retention efforts for some time (Booker, 1987). Pertinent information from these interviews will be referred to in our discussion of minorities in allied health education. Table 5-2 presents estimates of racial and ethnic characteristics of allied health personnel based on the results of an analysis of the 1980 census. The data show that minority personnel are underrepresented, relative to their representation in the U.S. labor force, in the 10 allied health fields studied by the committee and particularly in the fields requiring higher education. CAHEA reports that over the entire range of the fields it accredits the racial mix of students enrolled during 1986-1987 generally mirrored the racial mix of the U.S. population. Blacks represented 11 percent of total enrollments, Hispanics, 6 percent, and American Indians, about 2 percent. What these data fail to reveal is that minorities are overrepresented in fields requiring less education and underrepresented in fields requiring more education. The extent to which minorities have a higher departure rate from programs and careers is not known. Several professional associations in fields requiring baccalaureate and advanced degrees have commented on the need for greater efforts to increase the number of minority students. For example, the 1984 Study Commission of the American Dietetics Association noted: While no effort has been made in the past to restrict other racial groups, or males, from the profession, little has been done to make the profession more attractive to them, nor has any strong effort been made to recruit them. The 1984 Study Commission believes such an effort is overdue. TABLE 5-2 Distribution of Personnel (Percentage) in Selected Allied Health Occupations by Race or Ethnic Origin, 1980 Minority Occupation White (not of Black Whit Other Spanish (Spanish Minoritya origin) origin) Laboratory 79.5 11.1 3.3 6.2 technician Dental hygienist 95.4 1.6 1.6 1.3 Dietitian 84.6 6.7 1.9 8.0 Medical record 84.4 9.5 2.2 3.9 technician Occupational 94.7 2.1 0.9 2.4 therapist Physical therapist 93.4 3.3 1. I 2.0 Radiologic 86.2 7.7 3.7 2.4 technician Respiratory 82.1 10.0 4.9 3.1 therapist Speech and 92.9 4.3 1.5 1.3 hearing therapist a These figures include American Indians, Japanese, Chinese, and other Asians or Pacific Islanders. SOURCE: Health Resources and Services Administration (1984). 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 168 Past Efforts To Increase Minority Participation The Federal Government The federal government first initiated programs to encourage ''culturally or economically disadvantaged individuals'' to enter allied health as part of the 1970 health manpower legislation (P.L. 91-519). This statute was extended in 1973 by the Comprehensive Health Manpower Act (P.L. 92-157) and the Health Programs Extension Act (P.L. 93-45) and in 1976 by the Health Professions Educational Assistance Act (P.L. 94-484). Later, an administrative decision was made to provide support for projects that emphasized the recruitment and retention of minorities as well as the disadvantaged (Carpenter, 1982). Between fiscal years 1972 and 1977 approximately $20 million of a total of nearly $191 million of grants awarded for allied health were allocated for programs targeting minority and disadvantaged populations. Between 1978 and 1981, under P.L. 94-484, a larger share of the total but a smaller amount was awarded for project activities to assist disadvantaged allied health students (Carpenter, 1982). By fiscal year 1982 the only federal funding of any magnitude that was available for minority recruitment and retention in allied health training was the Health Careers Opportunity Program (HCOP). HCOP has five objectives: (1) recruitment, (2) preliminary education (noncredit), (3) facilitation of entry, (4) retention, and (5) information dissemination. Examples of HCOP activities include career fairs; faculty counseling; tutoring; summer enrichment programs to enhance mathematics, science, and communication skills; and linkage arrangements among undergraduate schools such as historically black colleges and universities (HBCUs), community colleges, and high schools. Between fiscal years 1982 and 1987 the number of allied health grants under HCOP increased steadily, as did the funds that were awarded. Of the $60 million or more awarded since fiscal year 1985, $5.37 million has gone to allied health programs. The proportion awarded each year to allied health programs rose from 5 percent to nearly 10 percent during this 3-year period (W. Holland, Division of Disadvantaged Assistance, Health Resources and Services Administration, personal communication, 1987). The Area Health Education Centers (AHEC) Program assists health professions schools in improving the distribution, supply, quality, utilization, and efficiency of health care personnel in the health care service delivery system by encouraging the regionalization of professional education. The program has no legislative mandate to recruit and retain minorities, but it has explicitly encouraged such activities. In fiscal year 1987, AHECs in Arizona, New Mexico, Texas, California, Oklahoma, and at three black medical schools —Drew (Los Angeles), Meharry (Nashville), and 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 169 Morehouse (Atlanta)—were cited by AHEC officials as having active commitments to training professionals to serve Hispanic, Indian, and black populations. The AHEC financial investment in the recruitment and retention of minority allied health students and workers was not obtainable from available program data (Area Health Education Centers Program, 1987). States The health professions education programmatic resources of most states have been devoted to increasing the supply of minority physicians and dentists, but a few states support initiatives for minorities in allied health training. For example, Connecticut funds the Health Sciences Cluster Program, which exposes high school students to allied health professions; economically disadvantaged students in allied health in Georgia are eligible for a small grant program, the Regents Opportunity Grant Program (Mandex, Inc., 1987). New York State has developed an action plan to improve minority access to the licensed professions (including dental hygiene, speech-language pathology and audiology, physical therapy, and occupational therapy), the core of which is a comprehensive effort to improve curriculum development and teaching in mathematics and science in grades 7 through 12. In addition, the state offers financial assistance to allied health students willing to work in state agencies after graduation (New York State Education Department, Bureau of Higher and Professional Education Testing, 1985). Allied health is rarely specifically identified in state legislation for targeted funding. Several investigators report being unable to ascertain the amount spent for allied health education because these funds are not distinguished from appropriations for "medical education." Of the 13 allied health program officials interviewed (Mandex, 1987), only one reported that the program received funds for minority recruitment and retention through a line item in the state budget. Private Foundations Private organizations also see merit in encouraging minorities to select health care careers. The Josiah Macy, Jr., and Robert Wood Johnson foundations have been quite active in these efforts. However, Robert Wood Johnson Foundation staff report that current activities do not include allied health professions. Macy has sponsored some allied health professions training, but its primary focus, after more than 20 years of involvement in minority health professions education, is still physicians. The Macy experience is worth describing in some detail because of its potential applicability to allied health education. (The following description is taken from Bleich [1986, 1987].) 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 170 The basic concept of Macy's high school model is to use foundation funds to supplement tax levy support for participating schools. Strengthening curriculum and premedical advising early in a high school student's education is the centerpiece of this program. Linkages between colleges and universities and the high schools are common and serve as vehicles for faculty development, student exposure to careers, and academic enhancement. For example, five high schools located in the three poorest (50 percent of all families live below the federal poverty level) counties in rural Alabama have completed a 4-year cycle in the Macy project. Macy reported the following results. • Of the originally selected 114 students, 79 percent were retained in the honors program. • All of the honors students scheduled to graduate did so and are going to college; all but two anticipate attending a 4-year school. • Thirty-three of the 88 graduates specified that they would pursue a health career; 3 specifically cited physical therapy. • The Macy graduates took the mathematics placement exam given to all University of Alabama incoming freshmen. Of the group, 88 percent placed into calculus or precalculus—55 percent in calculus and 33 percent in precalculus. Macy notes that less than 10 percent of all Alabama freshmen did as well (Bleich, 1986). The program in these schools, which is called the Biomedical Sciences Preparation (BioPrep) Program and operates in grades 9 through 12, is conducted in conjunction with the University of Alabama School of Community and Allied Health, a school committed to increasing the number of health professionals practicing in rural Alabama. Many of the Macy graduates (57 of 88) were awarded tuition scholarships by the university. Prior to the BioPrep program, school systems in the three counties (two of them predominantly black with a median of 8.5 completed school years) were unable to identify gifted and talented youth. Initially, there were concerns about the schools' ability to attract sufficient numbers of students for the program; those fears have proved to be unfounded. Macy schools were able to attract more than 100 young people to their rigorous academic programs that emphasized science, mathematics, and language skills. In addition, new classes are being enrolled in several schools, and "in each setting there is growing interest and demand for a more rigorous curriculum" (Bleich, 1986, 1987). Extensive in-service training has taken place, and curriculum development has been a collaborative activity among high school teachers, BioPrep staff, and selected university faculty. Tutorials, enhanced science laboratories, and independent study have been offered at the schools; bimonthly 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 171 Saturday sessions and 6-week summer programs have been held at the University of Alabama. The Macy Foundation reports that more than 1,200 students have enrolled in their projects. It estimates that more than 4,500 students will be enrolled in grades 9 through 12 when the programs are fully established and that schools will graduate 700 college-prepared minority students each year. Other high schools in the project report results similar to the Alabama experience, lending credence to the potential of a model that blends public and private resources to produce systemic changes that can be institutionalized for long-lasting benefit. Lessons That Have Been Learned More than 20 years of experience in attempting to increase the number of minority allied health professionals suggest four areas that should be targeted for action: • academic preparation, especially in the sciences and mathematics; • knowledge of allied health careers and the promotion of minorities; • financing of institutions and students; and • linkages and affiliations in training and employment. Despite efforts of the federal government and individual institutions, the barriers to allied health careers for minorities that were cited in the early 1970s remain serious problems. Can lessons gleaned from past efforts inform policymakers and educators about what kinds of investments need to be made in the future, where they will be most productive, and which stakeholders can lead and contribute to greater success? Academic Preparation Astin (1985) notes that minority underrepresentation in engineering, biological sciences, the physical sciences, and mathematics can be linked to low levels of academic preparation in mathematics and science prior to college enrollment. Academic preparation is also the central issue that affects the size and quality of the minority applicant pool for allied health training. Allied health deans and program directors firmly believe that streams of qualified minority applicants cannot be relied upon until academic deficiencies are substantially reduced (Committee/staff interviews, 1987; The Circle, Inc., 1987). HCOP grantees typically have focused on strengthening the skills of disadvantaged students in communications, mathematics, and the sciences, with 6-to 8-week summer enrichment and tutorial programs the usual 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 172 interventions. Although there is partial evidence (La Jolla Management Corporation, 1984) that such interventions can work, the conventional wisdom is that the emphasis on mathematics and science should begin as early as possible, starting at or even before junior high school (Bisconti, 1980; National Commission on Allied Health Education, 1980; Flack, 1982; La Jolla, 1984; The Circle, Inc., 1987; Mingle, 1987). Perhaps allied health schools could gain more in the long run by helping to create alliances with others in the community to attack the root causes of poor academic preparedness. Allied health schools generally draw their students from known "feeder" sources. Strengthening academic preparation at the secondary school level and in other major feeder schools (e.g., community colleges) can contribute to lasting improvements in the quality of their applicant pools; it can also influence curriculum improvement at feeder schools and bring greater visibility to allied health career opportunities. At the same time, early academic and career counseling, a compounding factor (Committee/staff interviews, 1987; La Jolla, 1984; The Circle, Inc., 1986), can be enhanced. The Josiah Macy, Jr., Foundation provides an excellent example of what can be accomplished if students are introduced to intense academic skills improvement programs early. Macy's success also offers an example of what can be accomplished by approaching problems from a broad perspective. The foundation incorporated a wide variety of resources and addressed areas other than the student's grade point average. It also concentrated on raising school administrators' and teachers' expectations of students, educating parents, acting as a liaison to establish collaborations between colleges and public secondary schools, and raising students' self-esteem. Knowledge About And The Promotion Of Allied Health Professions Information plays a role both in attracting minority students to careers and in keeping them through training. Informing minorities about the wide range of allied health occupations and promoting these fields as career options are important steps in attracting minority students to these professions. Educators believe that better information about an occupation's training and practice is crucial to the relatively high attrition rate of minority students in the first year of professional training. Such information is not easily acquired, however. Allied health professions are not widely mentioned in the media, nor are the contributions of allied health occupations to health care delivery explained. Those interviewed for the study reported that information dissemination through career days, the distribution of brochures, and active recruitment 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 173 is most effective when coupled with formal and informal linkages with feeder high schools and colleges. One school that recently began recruiting through churches reported that they were a rich and largely untapped source of minority allied health applicants (Booker, 1987). Research data and the experiences of recruiters suggest that the following factors should be taken into account in shaping effective information dissemination and promotion campaigns (The Circle, Inc., 1987; Mingle, 1987): • Minority allied health students are likely to be older than liberal arts students; they are also more likely to have children. • Students who demonstrate potential in high school or community colleges may make up a greater percentage of the applicant pool than high achievers who are already being heavily recruited for medicine, engineering, and other professions. • Community colleges can become a good source from which to draw students interested in earning a bachelor's degree, especially if linkage arrangements that incorporate approaches to sharpening critical skills and increasing students' awareness of career options are implemented. • Persons who are disenchanted with their current occupations in other fields may be seeking an opportunity to pursue a new, more challenging and rewarding career. Financing For Institutions And Students Deficiencies in academic preparation are fairly widespread among minority allied health students, and deans of allied health schools expect this shortcoming to continue in the near term. They believe that financial support will continue to be needed for activities that help struggling students remain in school. These activities include prematriculation summer programs, faculty and peer tutoring and counseling, computer-aided learning assistance or instruction, and curriculum improvement/faculty development in feeder schools. Deans of allied health schools have concluded that external support, such as that provided by HCOP, is essential to underwrite some of these institutional expenses (The Circle, Inc., 1987). In general, intensive minority recruitment and retention activities are supported, at least in part and frequently at a substantial level, by external funds. HCOP has been predominant here for all activities except curriculum improvement in allied health training programs. A 1984 assessment of HCOP-supported preparatory activities (i.e., preliminary education, entry facilitation, and reten 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 174 tion) concluded: "Since by far the largest expenditures for HCOP are for preparatory activities, it is essential that HRSA [Health Resources and Services Administration] and the grantees focus special attention on providing those preparatory activity services that produce the greatest benefit to the objectives of the HCOP program" (La Jolla Management Corporation, 1984). Since 1978 funding for allied health under HCOP has increased as a proportion of the total HCOP investment, but total funds for the program as a whole have diminished and authorized purposes have been more narrowly defined. For example, there are currently no federal programs that support minority allied health faculty development or curriculum improvement in minority schools or in nonminority schools that view curriculum changes as one way to recruit and retain more minorities. The preeminent Minority Access to Research Careers (MARC) and Minority Biomedical Research Support (MBRS) programs, the oldest of the existing minority-oriented programs administered by the National Institutes of Health (NIH), support these kinds of activities, as do other, similar programs. Such programs have been credited with substantial contributions in increasing research, research training, and the number of researchers in institutions that train large numbers of minorities. Included in this cluster are significant numbers of traditionally and predominantly minority schools (Garrison and Brown, 1985; Gonzales, 1987). Along with a lack of institutional support, insufficient student financial aid is also seen as a deterrent both to minority student recruitment and retention. Allied health deans cited lack of funds as a major reason for student attrition. Many minority allied health students are older and have children; many of them find that school schedules generally do not permit them to continue working. In such circumstances, financial aid is a crucial factor in their persistence in working toward a degree. Bisconti (1981) notes that "a degree in an allied health major frequently is more expensive than a liberal arts degree." Tuition costs may not be higher, but there may be additional costs for clinical education and materials or equipment. Furthermore, the period of training (both preprofessional and professional) may be longer. Although states are investing in educational support for minority health professionals, the size of these investments varies widely, and most state aid is targeted toward medicine and dentistry. The committees' interview respondents felt that states needed to provide more student financial aid. Models that have successfully contributed to shifting the distribution of medical and dental professionals (e.g., the National Health Service Corps, loan forgiveness, AHEC) offer incentives for minority professionals to work in underserved areas. These are strategies that may be equally effective for allied health practitioners. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 175 Linkages And Affiliations In Training And Employment Linkages among colleges and high schools are playing an increasingly important role in encouraging the training of minority allied health professionals. Directors of allied health programs with and without HCOP grants acknowledge their value in recruiting students. It appears that linkages with high schools for recruitment purposes are becoming formalized, perhaps in response to HCOP's continued emphasis on such linkages since 1981. Data show that there are more linkages between schools and 4-year historically black colleges and universities than between high schools and community colleges. However, some schools that today lack community college linkages report plans to explore these arrangements. Linkages appear to work well when there is shared commitment and mutual benefit, regardless of whether the arrangement is formal (as in a written agreement that specifies responsibilities and benefits) or informal (a working relationship). The predominantly minority schools contacted by the committee reported no difficulties in finding adequate clinical placements for their students. These placements were most often in areas with large minority populations. Today, programs are quite dependent on hospitals for placements and have limited experience with other kinds of sites for student clinical training; thus, clinical training may be threatened if hospital revenues are reduced. Yet, several schools reported that clinical sites pay the tuition for students they accept for clinical placements, usually because the hospital is interested in hiring students who train with them. This interest should help sustain affiliation agreements between schools and hospitals, especially if workers are scarce. No strategy for significant increases in minority participation in the allied health professions will be successful unless it directs resources toward the major barriers to minority participation and involves the complete spectrum of interested parties, both in government and in the private sector. Minority recruitment efforts must begin before high school. Academic institutions must offer support services for retention and seek to promote educational mobility. To succeed in the long term, these efforts must be made integral to the mission of the educational institutions. Ultimately, success will depend on the ability of educational institutions to make a long-term commitment to integrating minority recruitment and retention into the fabric of their allied health programs. The erosion of federal support for this objective would undermine those in the education community who are struggling to gain or maintain such a commitment to minority allied health education. The committee endorses the objectives of HCOP and believes that funding levels must be maintained at least at current levels. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 176 MAINTAINING AND EXPANDING EDUCATIONAL CAPACITY The future supply of new graduates in allied health fields depends not only on students' careers but also on the maintenance and expansion of educational opportunities. Hospital-sponsored allied health education programs suffered more closures than any other types of programs. Between 1982 and 1986, 315 hospital-sponsored programs closed, compared with a small number of proprietary school closures. By contrast, there was a net increase in programs at community colleges (100 new programs, or 9.6 percent) and junior colleges (26 new programs, or 4 percent) (CAHEA, 1987a). Table 5-3 shows the net change between 1982 and 1986 in selected CAHEA-accredited allied health programs. Much of the decline in allied health educational capacity can be attributed to the closing of hospital-based training programs—principally programs in laboratory and radiologic technology. Programs that have the largest number of withdrawals from CAHEA accreditation (and that are presumed by CAHEA to have closed) are medical technology (116), radiography (103), and respiratory therapy technology at the certificate level (29) (CAHEA, 1987b). Among programs that are not accredited by CAHEA, physical therapy grew rapidly—from 84 baccalaureate programs in academic year 1980-1981 to 97 programs in 1985-1986; master's degree programs increased from 9 to 14 during the same period (American Physical Therapy Association, 1987). TABLE 5-3 Changes in the Number of CAHEA-Accredited Programs in Selected Allied Health Fields Between 1982 and 1986 CAHEA-Accredited Number of Number of Percentage of Programs Programs in Programs in Change 1982 1986 Negative Change Medical laboratory 73 47 -35.6 technician (certificate) Medical technologist 639 516 -19.2 Radiographer 790 701 -11.3 Respiratory therapy 188 169 -10.1 technician Nuclear medicine 138 128 -7.2 technologist Medical record 57 53 -7.0 administrator Positive Change Medical record 85 87 2.4 technician Occupational 56 63 12.5 therapist Medical laboratory 187 214 14.4 technician (associate degree) Respiratory therapist 204 235 15.2 SOURCE: CAHEA (1987a). 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 177 There is no clear evidence that capacity in higher education institutions is in serious jeopardy. Nevertheless, program closings, coupled with fears of a decline in the number of applicants, have heightened allied health program directors' feelings of vulnerability. These feelings, which were expressed by educators to the committee during its deliberations, arise from a threefold concern: (1) allied health education will not be able to maintain its foothold in research universities; (2) clinical education sites will grow scarce; and (3) financially stressed educational institutions of all types, viewing allied health as a costly endeavor, will close allied health programs. Given the nation's projected need for allied health personnel and their relatively short stay in the allied health work force, any serious erosion of the education sector's capacity to supply the nation with allied health personnel must be avoided. The question for public policy action is whether vulnerability poses a real and present danger that cannot be addressed by market forces alone. If government intervention or private efforts, or both, are required, what actions will offer the greatest return on public and private investments? To answer this question, we must first understand the roles of various important decision makers and how their actions can strengthen or weaken allied health education programs. WHO INFLUENCES EDUCATIONAL CAPACITY DECISIONS? The decisions to open or close allied health programs or to expand or contract enrollments are ostensibly in the hands of educational institutions themselves. Typically, a dialogue occurs between a dean or department head and the chief administrator for academic affairs about the desirability of adding programs or the need to close or reduce the enrollment level of a program. The remarks of one university president who was responsible, earlier in his career, for manpower projections at one of the allied health professions associations provide some interesting insights into the context of this dialogue: It obviously becomes extremely difficult for a university president to justify the continuation of this or any other program when student demand has moved elsewhere, say, to real estate, and when the dean of the school of business is clamoring for those scarce resources to be diverted to their front. Further, since the average age of my faculty is only 49, natural attrition does not facilitate resource shifts. It would be easier for me to justify maintenance of high cost programs if external support were still flowing to my campus; however, as you are well aware, there has been a steady decline in the amount of federal dollars available for health education. Therefore, academic administrators are on the horns of a dilemma, and now, like health care administrators, we must monitor the environment continuously and respond to changes as never before. Strategic planning is the name of the game. Universities can no longer afford to be all things to all people. (Perrin, 1987) 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 178 Decision making does not take place in isolation, and many parties can be involved in precipitating a dialogue and influencing its course. These parties include federal agencies such as the Bureau of Health Professions, state higher education and licensing agencies, state political leaders, accrediting bodies, professional associations, and local health care providers. At times, the pressures exerted by these parties and conversely, the opportunities they have offered schools, through grants, for example, so overwhelm institutional autonomy that it is difficult to discern where control lies. The issue of control is important: by understanding the distribution of authority over allied health education, we can identify how the forces that shape decisions about educational capacity can be influenced to accomplish public policy goals. These goals encompass not only the size of enrollments but the quality of education, its content, and the ability of the educational system to add to the nation's work force. The Federal Role A major, direct influence on the development of allied health manpower training capacity has been the federal Bureau of Health Professions and its predecessor organizations. In 1966, not long after Congress enacted federal education funding for medicine, osteopathy, dentistry, veterinary medicine, optometry, podiatry, and pharmacy in one law and nursing under another authority, it also provided education funding for 13 allied health fields. The Allied Health Professions Personnel Training Act offered five types of grants: 1. Construction grants for training centers and affiliated hospitals. 2. Basic improvement grants awarded on the following formula: $5,000 times the number of eligible curricula in the center plus $500 times the number of full-time students receiving training. 3. Grants to support traineeships for allied health personnel to become teachers, administrators, or supervisors or to serve in allied health specialities. 4. ''New methods'' grants to allied health training centers for projects to develop, demonstrate, or evaluate curricula for the training of new types of health technologists (U.S. Department of Health, Education, and Welfare, 1979). 5. Special improvement grants to support projects or centers that would provide no fewer than three curricula with the aid of this funding. Table 5-4 shows the funding history of this law and its successor pieces of legislation. Although no federal programs have specifically supported allied health training since 1981, allied health students and schools are 

TABLE 5-4 Division of Associated and Dental Health Professionsa Grants, Cooperative Agreements, and Contracts Awarded (in dollars) in the Allied Health Area, Fiscal Years 1967 through 1986 Fiscal Year Advanced Training Special Improvements Special Projects Basic Improvements Other Total Traineeships Institutes 1967 241,977 0 0 0 3,285,000 0 3,526,977 1968 1,203,648 0 0 799,507 9,750,000 0 11,753,155 1969 1,549,772 0 0 1,225,000 9,750,000 0 12,524,772 1970 1,538,064 0 0 1,231,938 9,701,000 0 12,471,002 1971 2.460,851 482,838 0 4,482,617 9,701,000 0 17,127,306 1972 2.585,936 324,064 10,500,000 7,628,384 0 0 21,038,384 1973 1,951,598 1,139,555 7,000,000 5,639,408 0 0 15,730,561 1973b 0 0 10,500,000 0 0 0 15,999,947 1974 2,563,000 999,888 16,000,000 10,126,537 0 0 29,689,425 1975 2,606,713 956,267 10,192,034 6,869,220 0 0 10,624,234 1976 2,563,000 1,000,000 10,499,999 8,197,432 0 0 22,260,431 1977 2,331,580 638,312 8,910,000 8,406,537 0 0 20,286,429 1978 1,443,562 924,070 0 14,345,813 0 0 16,713,445 1979 1,493,949 1,004,907 0 8,151,264 0 0 10,650,120 1980 887,062 0 0 4,251,671 0 738,961c 5,877,694 1981 0 0 0 508,143 0 364,516c 872,659 1982 0 0 0 0 0 0 0 1983 0 0 0 0 0 0 0 1984 0 0 0 0 0 908,550d 908,550 THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 1985 0 0 0 0 0 883,525d 883,525 1986 0 0 0 0 0 0 0 Total 25,420,712 7,469,901 73,602,033 87,363,418 42,187,000 38,101,018 274,144,082e a Prior to 1983, the agency was known as the Division of Associated Health Professions. b Released impounded funds. c Military Experience Directed Into Health Careers (MEDIHC) cooperative agreement funds. d Grants for allied health personnel in health promotion and disease prevention. e The grand total includes contract award amounts; contract amounts awarded by fiscal year are not available at this time, however. 179 SOURCE: Bureau of Health Professions Health Resources and Services Administration, unpublished data. 1987. Rockville, Md. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 180 eligible for funds under several general health professions education authorities, including • the federally-insured HEAL Student Loan Program; • educational assistance to disadvantaged students; and • health professions special initiatives (grants for special projects in areas such as health promotion and disease prevention; curriculum development in health policy, clinical nutrition, and the application of social and behavioral services to the study of health care delivery; the development of mechanisms for ensuring the competence of health professions; and the development of instruction, including clinical affiliations, in geriatrics). Efforts to assess the impact of federal funding have been stymied by a lack of data. A major federal report on allied health concluded the following: It appears that it [federal funding] added impetus to a trend that was already underway ... much of the private sector growth in educational programs that occurred between 1966 and 1971 without allied health grant support may have occurred in expectation of federal assistance. Quite apart from the question of the relative importance of federal support in increasing allied health manpower output is the problem of determining what the increase was and where it occurred. Prior to establishment of a federal role in allied health manpower, there was insufficient interest in the problems to allow the collection of data on educational programs. Not until 1972 was reliable information obtained on the type and amount of training offered by colleges and universities. Some collegiate program growth occurred at the expense of hospital-based programs and on-the-job training, another factor for which there are no reliable data. (Bureau of Health Manpower, Health Resources Administration, 1979) Other segments of the federal government have also played roles. The Health Care Financing Administration, through the Medicare program, has provided support for clinically based education. The Department of Education has helped through its general support of higher education loans and scholarships and in its specific provision of vocational-technical training. The Veterans Administration and the military services have also played a part in civilian training as they train personnel for their own needs. Finally, the Department of Labor has been concerned with entry-level occupations, offering training through the Comprehensive Employment Training Act (CETA) program and later through the Job Partnership and Training Act (JPTA). The State Role Through their involvement in higher education financing and regulation, states are a major force in determining the number and distribution 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 181 of allied health programs. In 1976 (the last year of complete data), 71 percent of public collegiate institutions had at least one allied health program, but only 36 percent of private schools offered allied health education (National Committee on Allied Health Education, 1980). The propensity to invest in allied health education depends in part on the health of the state's economy. In one of its workshops the committee explored decision making in three states—Texas, Illinois, and New York. Participants included representatives of higher education coordinating authorities, general collegiate administrators, and allied health school deans from different types of institutions. They described decision making and a sense of vulnerability that was related to the economic health of their regions. Allied health program administrators in Texas, where tax revenues have been falling because of the declining oil industry, felt at greatest risk. The Texas allied health educators believed themselves to be the first line of defense against medical school cutbacks. The economic situation was somewhat better in Illinois, but overall state higher education cutbacks were forcing state college systems to plan their responses to budget cuts if a pending tax increase did not occur. One school system, having already raised tuition the previous year, had directed its deans to consider the implications of a 5 percent budget reduction. The options available to one allied health dean included the following: (1) not filling vacant faculty positions, (2) offering some courses once instead of twice that year, (3) canceling planned equipment purchases, and (4) closing the school's physical therapy program, which needed more space. At the time of the workshop, New York State deans and policy officials were focused not on budget cuts forced by the state's economic picture but on the state's responsibility for ensuring an adequate supply of health care personnel. A state health department task force had recently been formed to explore "critical shortages" in nursing, home health care, and physical therapy services. One issue prompting the creation of the task force was the inability of state chronic care facilities to recruit therapists. Deans attending the committee's workshop identified faculty shortages as a major impediment to expanding education programs and enrollments in physical and occupational therapy. Statewide planning frequently occurs under the auspices of state higher education coordinating bodies, which are responsible for approving new education programs. In evaluating new programs, the coordinating bodies consider such issues as geographic maldistribution of programs and practitioners and the impact of new programs on minority participation. Decision makers who participate in this policy arena often must be reconciled to the fact that the politics of higher education planning (deciding, for example, which among competing institutions should receive the new pro 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 182 gram) may not lead to the conclusions that make the most sense from a health planning standpoint. States emphasize different values in their review of criteria for new programs. Missouri notes that its "State-wide review is principally interested in the state's need for programs and services, and resource allocation issues. That is, the statewide need for particular programs and the appropriate means of financing these needs to assure Missouri's citizens financial access to quality educational experience" (Missouri Coordinating Board for Higher Education, 1986). In contrast, Texas has stated that "The expenditure of public tax funds for educational programs in any occupational area is a matter of public policy directed at meeting a public need that cannot or will not be met otherwise. Student interest is not the major concern for expenditure of public tax funds for an occupational training program" (Allied Health Education Advisory Committee, 1980). The ability of state coordinating bodies to enforce their resource allocation policies varies. Some state authorities may only be able to apply "jawboning" tactics to influence institutional decisions. In some cases, battles are fought during the state legislature's higher education budgeting process—through a specific line-item request for a new program, for example. Depending on state political tradition, legislators may choose to wield influence in favor of constituent educational institutions and in response to lobbying efforts. More often, however, the survival of allied health programs is brought into question when academic institutions find themselves forced to reallocate institutional resources as a result of a budget crisis. In some states, higher education coordinating/governing bodies have statutory review powers for new programs. The Private Sector Role The private sector role can be seen in the activities of accrediting bodies, professional associations, and foundations. Accrediting Bodies There are a multiplicity of issues surrounding who should control accreditation, how it should be structured, and whether it could be a less costly process. This discussion, however, will focus on accreditation standards, which have a major impact on collegiate decision making about new or expanded programs. Program administrators must take into account the cost of complying with the standards of accrediting bodies and the recommendations of site review teams. For example, programs sometimes close because they cannot maintain the student-faculty ratios, equipment, or space required by an accrediting body. Often, there is a clash between the accrediting body (which believes its essentials ensure basic minimum standards) and gen 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 183 eralist academic administrators (who see site review recommendations as a tool to be used by departmental chairmen to get more support for their programs). Professional Associations Historically, much of the educational activity of allied health professional associations has been in promoting the shift of educational programs from hospitals to academic institutions. Once this shift was accomplished, an association's interest often centered on raising the entry level of the profession or on creating assistant-level categories of personnel. Today, associations' educational activities range more widely. They might include consultation to academic institutions contemplating new program offerings, workshops for administrators and faculty, student recruitment programs, and the maintenance of education data bases. Some associations have assumed quasi-regulatory functions in the education accreditation arena. For example, accreditation responsibilities for dietetics, physical therapy, and speech-language pathology and audiology are handled through independent entities operating in conjunction with the professional associations. It should be noted, however, that some of the allied health fields do not have a well- organized professional association that can engage in educational activities. Supplementing the work of the associations are the American Society of Allied Health Professions and the National Society of Allied Health—two umbrella organizations that cut across disciplinary lines in an effort to help their members address educational issues common to most fields. Because of an extensive literature and the activities of the Federal Trade Commission in questioning the role of the American Medical Association in limiting the supply of physicians through medical education, it is reasonable to raise the question of whether allied health associations influence the supply of practitioners in their respective fields, restricting entry as a means of enhancing the economic status of their members. An investigation to determine such influence, however, was beyond the scope of this study. Private Foundations Complementary to the role of federal and state support is the contribution of philanthropy in generating experiments in allied health education. Principal among the foundations is the W. K. Kellogg Foundation, an organization that over many years has spurred institutional development and leadership activities and studies of allied health fields. Currently, the foundation is supporting a clearinghouse at the University of Alabama to clarify and promote the concept of multicompetency in allied health as well as supporting several activities of the American Society of Allied Health Professions. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 184 Why Is Allied Health Education Vulnerable? As indicated in the previous section's review of federal, state, and private roles, the era of direct efforts to expand the allied health education enterprise has ended. Yet the day-to-day business of federal, state, and private decision makers continues to shape allied health education. Federal Medicare reimbursement policy, state higher education budgeting and regulation, interest groups in pursuit of enhanced professional status, and educational accreditation are all powerful influences on the future of allied health education. How stable educational institutions will be in the future will depend on their ability to compete for higher education resources with other, more entrenched academic programs whose graduates may also be in high demand. Maintaining Ground In Academia A number of prestigious institutions—the University of Pennsylvania, University of Michigan, Emory University, and Stanford University, for example—have closed allied health schools and programs. A fundamental component of the rationale for closure appears to have been that the preparation of allied health practitioners did not sufficiently contribute to the aspirations of a research university seeking to concentrate its resources in areas of strength. As allied health deans see some of the most noteworthy programs close, they grow apprehensive about the future of their own programs. They are also concerned about the future of allied health programs because the programs lack the capacity to foster research and produce teachers and academic leaders (Broski et al., 1985; Hedrick, 1985). Although it is difficult to document the fragile condition of allied health education, the committee believes there is some basis for the deans' apprehension. Furthermore, the committee is concerned that closures have signaled to academic decision makers and public officials alike that allied health education may not be a sound investment for scarce educational dollars. As Table 5-5 (which is based on 1970s data from the National Commission on Allied Health Education) shows, these programs have long existed in almost every type of collegiate institution. The committee believes that there is no generic or inherent quality that disqualifies allied health education from life on any campus in the nation. The diversity and evolution of the many occupations suggest that some are more suited than others to various academic settings and degree levels. Yet the conclusions that are drawn today about a given field may change tomorrow as knowledge and practice evolve. Each type of collegiate setting has its advantages and disadvantages. Generally speaking, for example, academic health sci 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 185 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 186 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 187 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 188 ence centers have easier access to clinical resources and a wide range of opportunities for interdisciplinary experiences. However, as reported to the committee, the latitude for decision making and creativity of program design by deans and program directors has traditionally been more limited in academic health science centers than in schools of allied health that are independent of such centers. Community colleges shine in their ability to attract to diverse student populations who are job oriented. Educational programs there are tailored to suit the needs of employers and students in a given local community. To guide institutions in deciding whether to continue or start allied health education programs, the Southern Regional Education Board (1980) suggests that the following six questions be considered: 1. Mission Is the program consistent with the institution's philosophy and purpose? 2. Employment Will graduates be able to secure employment and will that employment satisfy the local, state, regional, or national mission of the institution? 3. Accreditation Is the institution willing to invest in a program, given the resource consumption implicit in achieving accreditation? 4. Students Will there be sufficient enrollment over a sustained period of time? 5. Budgetary? Concerns Is the institution prepared to adopt programs in which clinical components may require equipment, supervision, and costs that often exceed those of other types of academic programs? 6. Faculty Is there a sufficient faculty pool on which to draw? What resources will be necessary to attract qualified individuals to teach? Today, allied health education appears vulnerable on all but the 'employment demand' criterion. The key to improving allied health's bargaining position in academia is to demonstrate value to the parent institution that is striving to fulfill its mission of scholarship or community service. The recommendations that follow are designed to address some of the problems that prevent allied health programs from competing effectively for institutional resources and thus endanger their viability. Faculty Shortages Because many allied health fields are relatively new to collegiate environments and have grown rapidly in the past 2 decades, allied health educational programs often face both quantitative and qualitative problems in filling faculty positions. In physical therapy, for example, the number of accredited university programs grew from 48 in 1970 to 113 in 1986. The supply of faculty does not appear to have kept pace. A 1985 survey of academic administrators in these programs reported a need for 152 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 189 additional faculty simply to meet current demands (American Physical Therapy Association, 1985). As a result, many programs rely heavily on part-time lecturers without regular faculty appointments, faculty from scientific disciplines who do not hold professional qualifications in the clinical field, and professionals who lack the academic credentials that are traditionally expected of university faculty. For example, in its faculty survey the American Physical Therapy Association reported that only 28.2 percent of full-time faculty in physical therapy programs had doctoral degrees. This proportion was in clear contrast to national data that showed that 54.9 percent of all faculty teaching in institutions of higher education had doctorates (Newman, 1985). The recruitment of qualified new faculty is seriously hampered by the very limited pool of candidates. Even in relatively mature occupations such as occupational and physical therapy, professional associations report that only about 1 percent of all members have doctoral degrees and just over 24 percent have master's degrees (American Physical Therapy Association, 1987; American Occupational Therapy Association, 1987). In a survey of 124 medical record education programs (which constitute more than 80 percent of all programs), the majority employed only one or two additional faculty members besides the program director; no program had more than four full-time additional faculty. Only five of the directors of these schools had a doctorate. Among the 53 full-time faculty members in university-based programs, only 2 had doctorates, 33 had master's degrees, and 18 had baccalaureates as their highest academic degree (Amatayakul, 1987). Although some allied health professionals are enrolled in master's and doctoral degree programs, the lack of financial aid and the relatively low earnings of allied health clinicians force most of them to carry out this advanced study on a part-time basis over a long period. Lack of funding has also constrained the development of graduate programs in several allied health disciplines. Although advanced study in such related disciplines as physiology, psychology, or education benefits allied health faculty, the lack of graduate programs in their own disciplines has limited the number of allied health faculty who are active scholars in the field in which they have the greatest teaching responsibility. The options for producing faculty efficiently should be explored to maximize faculty development resources. The American Occupational Therapy Association has had some success in targeting faculty development efforts toward clinical faculty who might be inclined to pursue full-time teaching appointments (S. Presseller, American Occupational Therapy Association, personal communication, 1987). Another approach would be to focus attention on streamlined allied health certificate programs that give individuals with doctorates in other academic disciplines the opportunity to gain 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 190 a practice credential for teaching purposes. Holcomb and colleagues (1987) have described a partnership between Baylor College of Medicine, Texas A&M University, and the University of Houston that offers programs in allied health teacher education and administration that have been productive in supplying faculty nationwide. The rationale for a federal role in faculty development in allied health is similar to the justification for federal support of family practice programs in medicine. From 1972 through 1984, federal grants of more than $200 million fostered the growth of graduate family medicine training activities (Health Resources and Services Administration, 1986). Like allied health, family medicine exists today because the federal government was willing to promote a concept that was designed to address some of the health care system's deficiencies. As a relatively new endeavor, family medicine departments still lack qualified faculty and the ability to garner research funds from traditional sources such as NIH, in. part because of noncompetitive research credentials among faculty and in part because of the low funding priority of primary care research. Like allied health, family medicine has yet to prove itself to the academic medical center establishment—a task that is hindered by a reimbursement system that does not generally reward non-procedure-oriented faculty practice. Federal grants are being used to make the playing field more level for family medicine in the competitive medical school environment. Federal investment in family practice is based on the policy assessment that primary care needs are unmet and that these programs are a cost-effective means of producing and distributing primary care practitioners. Similar national goals relating to issues of rehabilitation, disease prevention, AIDS treatment, and geriatrics can be well served by the support of allied health education. The committee recommends that federal and state governments fund faculty development grants in allied health fields, especially in areas in which faculty availability and lack of clinical expertise inhibit the production of entry-level practitioners. Closely tied to the need to improve teaching faculty is the need to advance research in allied health. Research and other forms of scholarly activity are inherent features of academic life. Programs that fail to give sufficient weight to academic research, along with teaching and service to the institutions, are doomed to instability over the long run. In recognition of this fact and with the belief that the practice of any large group of health care professionals ought to be informed by an increasing knowledge base, the 1983 IOM study of nursing recommended that the federal government fund programs to increase the supply of doctorally prepared nurse researchers and support ''an organizational entity to place nursing in the mainstream of scientific investigation'' (Institute of Medicine, 1983). These 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 191 recommendations spurred the creation of the NIH Task Force on Nursing Research and, eventually, congressional action that established the Center for Nursing Research at NIH. In its final report the NIH task force concluded that the extramural and intramural program activities then supported by NIH were consistent with the mission of the institutes and that studies conducted with nurses as principal investigators and studies designed to improve nursing care (but not necessarily directed by nurses) could be fostered through a combination of activities. These activities were intended to help train nurse researchers, encourage greater collaboration by and interest on the part of medical scientists in interdisciplinary work, and enhance the capability of nurses to compete for research support (National Institutes of Health, 1984). Although there are few data to confirm the impression, it appears that the research capability of most allied health fields is less developed than that of nursing. In part, this increased capability of nursing may be due to the continuing commitment to research provided by the federal Nurse Training Act (Title VIII, Public Health Service Act) and the newly created Center for Nursing Research within NIH. Covey and Burke (1987) offer an additional explanation: Because qualified faculty by the traditional standards were not available, selection of our University faculty has often been largely from the practitioner ranks and from those who had perhaps acquired graduate degrees in such unrelated disciplines as education or administration. The focus of their training has been on technological competence and, in some cases, discipline pedagogy but has not always included research. By virtue of their own training, deans and directors themselves are often unable to develop the junior faculty and, in fact, too many deans and program directors either lack an understanding of or simply ignore the tripartite academic mission. In later chapters of this report that deal with issues of health care management and regulation and with long-term care, the committee notes decisions that administrators, payers, and regulators must make in the absence of an allied health research literature. Medical scientists and other researchers on their own will not and cannot define research priorities from among health care services delivery issues or the clinical applications that typically concern allied health practitioners. Although medical scientists should be encouraged to develop collegial relationships and undertake joint projects with allied health personnel, they are not as likely to be interested in the outcome measurement and cost-effectiveness issues that need to be addressed as are those who deliver the services. Allied health fields vary in their maturity with respect to a productive research capacity. Some fields such as dental hygiene, in which most practitioners have less than a baccalaureate, are only now beginning to explore 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 192 the possibilities of a cadre of research leaders to build a body of knowledge linked to a theoretical framework. This research should go beyond simple, unrelated pilot studies. It should define dental hygiene as distinct from dentistry and explore the efficiency of methods and modes of practice (Bowen, 1988). In contrast, other fields like speech-language pathology and audiology have many practitioners with master's degrees and doctorates and a rich history of tapping into a growing knowledge base in human communication services and disorders. Both fields, however, share a concern over the lack of relevant research finding its way to those who provide patient services—whether it be to the communicatively impaired (Ludlow, 1986) or to those seeking preventive services from a dental hygienist. A cadre of researchers and academic leaders is needed to advance the scientific base of allied health practice. To accomplish this goal, institutions with strong research commitments should consider developing programs that identify and nurture talented individuals. The committee recommends that a federal research fellowship program be instituted to support these activities. Financing Clinical Education The closing of hospital education programs discussed earlier in this chapter represents more than a long-term shift from hospital-based to academically based education. Hospitals with limited resources may reduce or eliminate clinical affiliations with education programs in addition to closing their own sponsored programs. As clinical affiliates attempt to trim their costs in response to reduced revenue, educators fear that hospitals will request remuneration for the supervision of students or seek other means of shifting costs back to the educational institution. As of 1987, it appears that this is not a large problem. When CAHEA (in press) queried education directors about changes over the past 3 years in the costs of the clinical portion of their programs, it received the following responses: 17 percent said they had experienced significant cost increases; 13 percent felt that program viability was threatened; and 15 percent perceived that the program had become a burden to the sponsoring institution. Only 7 percent reported a significant change in curriculum. Allied health educators are also concerned about long-standing proposals to constrain or eliminate Medicare payments for education. Currently, Medicare pays hospitals for the direct educational costs of allied health programs on a reasonable cost basis as an addition to the DRG payment. Payments are intended for provider- operated programs and not for affiliated programs in which the hospital provides part of the clinical training in a university-based program. For the latter, the costs of the training and its benefits to the hospital are presumed to balance one an 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 193 other. Since the passage of PPS, there has been some confusion over whether the costs of jointly sponsored programs are eligible for reimbursement. Presidential budget proposals to terminate Medicare funding for hospital- based allied health and nursing education programs have added to concerns that hospital financial managers, who are looking for every opportunity to reduce institutional costs, will eliminate clinical affiliations whenever feasible. To those attempting to find ways to reduce the federal budget, the direct support of educational programs represents an open-ended expenditure that is insufficiently targeted to the most important national human resources needs. Most often, these are thought to be the development of greater numbers of primary care physicians and fewer specialists. Several recent studies sponsored by the Health Resources and Services Administration to assess the impact of proposals to eliminate Medicare's educational support have provided a better understanding of the role played by this source of educational financing. A congressionally mandated study of nursing and nonphysician (i.e., allied health, as defined by the study) costs in educational programs approved for Medicare reimbursement, conducted by Applied Management Services, Inc., revealed that, together, these programs cost Medicare roughly $226 million in the second year of prospective payment. This figure is relatively small compared with the $42.7 billion the government paid to hospitals under Part A Medicare for the same period. The analysis of Medicare cost reports indicates that nonphysician health care education programs cost the 514 providers in the program a total of $167 million. Nursing programs were more expensive, costing 547 providers $533 million (Health Resources and Services Administration, 1987). Medicare pays only for its own share of the allowable direct costs. Other studies (Lewin and Associates, 1987; Mathematica Policy Research, Inc., 1987) have confirmed the observations of Applied Management Services in interviews with the directors of hospital education programs. Education programs offer numerous benefits to the employer, chief of which is the opportunity to recruit future employees. Additional benefits include motivating existing staff to stay abreast of advances in their fields, and enhancing the reputation of the hospital by providing a community service to local educational institutions. The committee believes that the federal government should not reduce its support on the presumption that employers—realizing the benefits of education programs—will maintain and even increase their support. Precipitate action to cut Medicare's educational support runs the risk of destabilizing vulnerable allied health education programs. In the committee's view, such destabilization is not worth relatively small, short-term budget savings. In the long run, Medicare beneficiaries would be harmed by lim 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 194 iting clinical experience for students. Moreover, many of these costs are likely to emerge later as potentially more costly recruitment and on-the-job training expenses. Therefore, the committee recommends that, until credible alternative approaches are developed, the federal government and other third-party payers maintain current reimbursement levels and mechanisms of support for clinical allied health education. The Comparative Cost of Allied Health Education Allied education programs are perceived by educational planners and administrators to be high-cost programs. As a consequence, they can be prime targets for institutional budget reductions by central administrative staff. Where state higher education funding formulas do not compensate for these higher costs, programs are exceedingly vulnerable to cost-cutting measures when times are hard in higher education. There has been growing recent interest in constructed cost models to improve the ability of allied health deans and program directors to negotiate with their central administration and explain why their unit costs may be higher than those of other fields. These models focus on key assumptions about faculty contact hours, faculty-student ratios, resource requirements for clinical experiences outside the department, and faculty salaries (Free-land and Gonyea, 1985). Although the models are useful tools for improving efficiency and then demonstrating those improvements to academic administrators, their explanatory power does not change the reality that allied health education is faculty intensive, that it necessitates clinical education experiences requiring coordination and supervision, and that it often has extensive laboratory and space requirements. The recommendations that have already been made in this chapter will help to address some of the weaknesses allied health programs have in competing for resources. Yet these measures are no substitute for the actions many allied health schools must begin to take to generate the revenue needed to thrive. Medical schools have come to rely increasingly on income generated from faculty practices. Although such activities may not be appropriate or financially advantageous for many allied health fields, they may be so for some if they are established with sufficient forethought and expertise. The notion of generating revenue by providing services needs further exploration, however. For example, the services provided by allied health schools might be educational (extension courses or adult education, for example), or they could involve innovative relationships with industry. To enhance the stability of allied health education, national organizations such as the American Society of Allied Health Professions should 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 195 investigate models in which academic institutions have succeeded in broadening their financial base through such mechanisms as faculty practice plans, extension courses, and industry relationships. The national organizations should also hold workshops to help institutions implement the models and to disseminate information. In undertaking revenue-generating enterprises, however, allied health deans will confront and possibly exacerbate a problem they have faced before. Faculty resources currently are stretched thin to control costs, and the excessive teaching load leaves little time for faculty to engage in scholarly activity, research, and college committee work. Yet these activities constitute a major portion of the traditional evaluation criteria for faculty promotion and tenure. Consequently, they are the preferred nonteaching activities pursued by faculty wishing to advance their academic careers. Maintaining state-of-the-art clinical competence further adds to the faculty's already excessive work load. Indeed, the committee heard a number of deans complain of the difficulties their faculty members face in maintaining clinical skills and of the concomitant impact of these difficulties on preparing students for the labor market. To ensure that the clinical competence of allied health faculty is maintained, the institutional award system must accommodate clinical competence because faculty allocate what little nonteaching time they have to those activities that are highly rewarded. The committee recommends that institutions that offer allied health academic programs reward and encourage faculty clinical competence. Clinical practice that sustains this competence should be made a requirement for promotion . It is noteworthy that this concern about the reward system is also one that medical educators have been forced to confront. As the president of the Association of American Medical Colleges has observed, "Despite the realization that teacher-clinicians are essential ingredients of medical facilities, the need is often not recognized by the parent universities whose appointments and promotion policies leave no niche for the clinician-teacher to receive proper recognition" (Petersdorf, 1987). Preparing Students for Tomorrow's Jobs In principle, sound educational planning would dictate that academic institutions base their program offerings on an understanding of the knowledge, skills, and socialization required of their graduates—not only for today's health care labor market but for the future as well. By extension, statewide higher education planning should take into account the mix and distribution of personnel at different educational levels that will be needed across the state. Confounding efforts at such rational planning, however, are a lack of clear signals from the labor market about future human 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 196 resource needs and continuing controversy about matching education to the requirements of the health care delivery system. Reflecting this controversy, an allied health education advisory committee in Texas highlighted a series of concerns that often surface when such groups view the broad spectrum of allied health fields (Allied Health Education Advisory Committee, 1980): • the growing amount of narrow specialization at all degree levels; • the requirements of some professional groups for higher levels of training for professional entry credentials; • difficulties with the transfer of credits to implement the career ladder concept; • the most appropriate levels of training for various kinds of allied health personnel; and • differences in the programs needed to prepare practitioners, master clinicians, teachers, researchers, and managers. Ironically, these issues are of concern today because, in the past, educational institutions have responded to student and employer demands. Associate degree and certificate programs were developed to provide students who were unwilling or unable to spend 4 years in school before entering the work force an opportunity to enter a field in which those workers with traditional higher credentials were in short supply. Academic health centers and 4-year colleges, in addition to community colleges, sought to meet the needs of their own and local hospitals with 2-year programs. Students with baccalaureates in other than health care fields were accommodated with certificate programs so they could pursue allied health careers. Students who were interested in careers in respiratory therapy, dental hygiene, and radiography, which were principally offered at the associate degree level, found themselves able to enroll in programs that also allowed them to obtain baccalaureate degrees. The result of these developments was the opening of allied health occupations to a wider range of participants. Having accommodated the needs of different student markets and employers who were either experiencing shortages in some personnel categories or who were attempting to structure their staffing with personnel of different educational levels, the educational system is now faced, not surprisingly, with a state of untidiness that planners find uncomfortable. Further complicating matters is the growing availability of graduate training. Although advanced degrees have long been accepted as appropriate preparation for faculty, administrators, and researchers, there is greater skepticism about graduate work when it comes to the elevation of a field's entry-level qualifications or efforts to develop specialities. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 197 The committee acknowledges this great diversity in educational qualifications but finds that a public policy problem requiring attention may not exist. The diversity in and of itself is not a problem. The test of whether specialization and changing qualifications or standards are dysfunctional is twofold: (1) Is there wastefulness in student educational investments? (2) Is the educational system responsive to society's need for a manpower supply that permits the health care system to function efficiently and provide care of the desired quality? Educational Investments by Students To open a new education program and admit a class implies a contract with students that contains certain assurances. No school can guarantee a student a job nor can it guarantee that skills and knowledge acquired in its programs will be marketable in perpetuity. Nevertheless, the committee believes that schools have the responsibility to ensure that (1) professional education is training for a specific, "real" occupation at the end of the line; (2) the program's general education content is sufficiently balanced by occupation- specific skills; (3) if, and when, students wish career advancement through education, there is a relatively efficient pathway to follow; and (4) there is a realistic balance between the role aspirations of professions with the realities of day-to-day work. In fulfilling their responsibilities to students, educational decision makers face a number of dilemmas. "Real" Jobs There are numerous job titles under the umbrella of allied health. Not all of them need to have separate, formal academic programs. Yet educators must be sensitive to changing technology and disease patterns that may warrant such recent developments as genetic counselors and MRI technicians. The Southern Regional Education Board (1980) has recommended—and the committee concurs—that academic institutions contemplating the development of new allied health specialities ask themselves three practice- related questions: • Are there any legal or professional restrictions on the new practitioners that will tend to inhibit employers from hiring these graduates? • Is the new speciality sufficiently different from existing specialities to justify the development of a new educational program? • What degree of liability does the supervisor of the new practitioners assume? Liberal Education Faculty in professional or technically oriented programs in higher education face a continuing struggle to reconcile the demands of academia for scholarship and general education with pressures 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 198 from employers and accrediting bodies to prepare students for technologically demanding jobs. The argument on the side of liberal education is that the educational program ought to be providing preparation for life and not just for a specific job. Graduates must be prepared to respond to the inevitable changes that will occur in society. Many educators feel the pressure that is exerted by employers (especially employers in fields that require familiarity with instrumentation) to influence programs to produce graduates who do not need extensive orientation. Even at the community college level, which has had a strong tradition of job orientation, there is concern about the appropriate mix of general education and technical/ clinical course work. In one small survey, 25 allied health community college deans reported proportions of general education to technical/clinical course work credits that ranged from 8 percent to 35 percent, with an average of 22 percent (Kaminski, 1987). In the name of responsiveness to a changing society, general education courses compete with pressures to incorporate such areas of study as geriatrics, computer applications, multicompetency, and clinical experience in alternative sites of care. The committee is sympathetic to the dilemmas faced by curriculum planners. Yet it is also concerned that students receive an educational foundation on which they can build a career if they so desire. Part of this foundation entails developing the capacity for and an interest in lifelong learning. A further, important benefit of such a foundation is that, if current skills become obsolete, practitioners have a base on which they can develop an alternative career. Articulation Allied health dean Elizabeth King from Eastern Michigan University describes two hypothetical students to illustrate the personal dimensions of the problems of articulation, the process by which students achieve upward educational transitions among academic programs (King, 1985). One student, having worked 7 years as a certified occupational therapy assistant "with a love of the profession and a conscious decision to build upon her current skills," is confused and disillusioned when denied the opportunity to transfer her professionally related course work toward an occupational therapy degree. Meanwhile, another student with an associate degree in general studies, hearing about the good job prospects for occupational therapists but having little knowledge about what occupational therapists do, is advised by the senior college that all of his courses will transfer and he can complete the degree in 2 years. In general, states have strongly promoted the concept of multiple entry and exit points in health careers to minimize the loss of student time in moving through certificate, associate, and baccalaureate programs. Without 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 199 strong mandates or incentives, however, such programs have difficulty overcoming some inherent barriers. King discusses a number of them. For example, curricular problems occur in judging the compatibility of didactic and clinical program content, which makes it difficult to assess advanced placement. There is also, at times, a lack of communication between academic affairs and admissions offices to work out problems regarding credit transfer policies. Finally, and perhaps most important, faculty professional biases, in King's view, "the most insidious barrier," create an environment of "undiscussable tension." These biases label community college students as "technically" trained and lacking in problem-solving experiences. The committee recommends that alternative pathways to entry-level practice be encouraged when feasible. State higher education coordinating authorities and legislative committees should insist on flexibility in educational mobility between community colleges and baccalaureate programs. Role Congruence There is continuing tension between health care administrators and professional groups over the tendency of a field to assume more sophisticated or broader responsibilities and the perception of employers (or payers) as to the legitimate and valued functions that need to be performed for patients. Professional associations and program faculty see their responsibilities as the defining and shaping of their discipline. This process is reflected in curriculum content and reinforced by accreditation. Health care administrators become concerned when they believe curriculum is being used as a precursor to expanding the legal scope of practice and reimbursement without recognition of what is possible or likely in practice. They also become concerned when they believe that an occupation is at the same time abandoning "hands-on" patient care for "professional" responsibilities that are not valued highly by those outside the field. Care must be taken to ensure that students do not become mired in these controversies. Ultimately, these issues are resolved by the market, as shaped by consumer tastes and employer hiring practices, or by public policy, as reflected in reimbursement or licensure decisions. While these issues are being resolved, however, the committee believes that educators have the responsibility to ensure that students have realistic expectations of what their prospective occupation is like today—and not only what it might be in the future. The Agreement Between Education and Services Along with the education program's responsibility to students is a responsibility to society to ensure that the health care system has the human 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 200 resources it needs to function well. Indeed, the rationale for the committee's support of public intervention in allied health supply issues is based on its belief that the link between services and education needs to be strengthened. In determining their program offerings, allied health educators are cautioned by state higher education leaders and health care administrators to avoid overtraining in both curriculum content and in length and level of preparation. On the other side are the professions who caution against too little training and who strive to elevate educational standards through licensure, program accreditation, and reimbursement standards. The committee has heard arguments by the first group that raising educational qualifications is not only expensive to the student but to the educational and health care systems as well, both of which are attempting to control costs. Furthermore, proponents of this view contend that ''education creep'' exacerbates shortages by lengthening the time required to prepare an individual for work. They also contend that there is little evidence to suggest that current levels of education are creating care problems. Counterarguments are most often based on the expanding knowledge base that practitioners need to master and the limited time available in the curriculum for such mastery. New sites of care, such as in the home or in independent office practice, require a level of judgment that can only be achieved with increased education. Those concerned with an adequate supply of practitioners point to the higher labor force participation rates and longer tenure of those who have already attained the higher credential. This committee encountered a number of these types of controversies among the allied health fields. Some examples include physical therapists attempting to establish the master's degree as the entry-level standard, role delineation debates among baccalaureate medical technologists and 2-year medical laboratory technicians, proposals to limit the educational routes to entry-level dietetics, and the movement of respiratory therapy to a baccalaureate entry-level standard. The case for promoting a single optimal level of education is an exceedingly difficult one to make on empirical grounds. For example, when an IOM committee explored the controversy over the three educational tracks leading to the registered nurse credential (associate degree, diploma, and baccalaureate), it was unable to find convincing evidence on the difference of performance among the graduates (Institute of Medicine, 1983). The committee neither endorses nor refutes the position of parties on either side of these debates. In view of the lack of objective empirical evidence and the limited scope of the present study, the committee could not justify offering conclusions that might influence the outcome of these controversies. The committee does suggest, however, that those making 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 201 decisions ensure that changing existing practice will not limit the supply of practitioners nor make care excessively costly. From the committee's perspective the only sensible response to the moving targets of health care system change and the lack of certainty about how to match education to future needs is a continuing feedback loop between education and practice. Graduate follow-up studies that incorporate employer perceptions are the most direct measures of how well the curriculum is preparing students. The aim of these studies, however, need not be solely to tailor education to employer perceptions of need. Rather, it should be the start of a dialogue. If students are not applying their educational experiences fully, the problem may at times rest with the work environment. A dialogue could potentially lead to a mutually beneficial set of activities involving more participation from health care managers in curriculum design and greater involvement of educators in health services research with practical application to clinical settings. Various models are available for institutionalizing such interactions. In some education programs, allied health education and services are jointly administered by the same corporate entity. An example is Rush University in Chicago where education and services are unified. Where this is not feasible, the industry advisory boards common to many community colleges can be used. Faculty practice plans or clinical affiliations may also be a starting point to stimulate collaboration. In those fields in which instrumentation plays a major role in job functioning, industry/faculty collaboration provides a largely untapped resource. Manufacturers ultimately have a stake in human resources because investments by health facilities in technological innovations may be seriously jeopardized if there is a lack of adequately prepared personnel. Manufacturers should consider collaborating with educational institutions in creative ways— for example, the use of equipment, faculty-industry research projects, short- term employment opportunities—as a means of ensuring an appropriate human resource infrastructure to assist technology transfer. Yet some stimulus is necessary to overcome the inertia of dealing with these difficult issues of collaboration. The committee sees a role both for states and private foundations in providing that stimulus. State legislatures should establish special bodies whose primary purpose would be to address state and local issues in the education and employment of allied health personnel. Private foundations should support university-based centers for allied health studies and policy to provide a critical mass of researchers and resources to advance technology assessment, health care services research, and human resource utilization. States have a major role in allied health education by virtue of their support of public colleges and universities. In addition to this influence, 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 202 they are frequently drawn into debates over licensure issues that involve changing scopes of practice and the licensing of new occupations. (These regulatory issues are discussed in Chapter 7.) Private foundations could have a major impact on the future of allied health education and practice by creating centers of excellence in a few academic institutions. Many advantages might be gained by coalescing a core research faculty that also provides services. These mutually reenforcing activities would enhance the quality of research and patient care. Furthermore, these centers might then be a resource to other allied health education programs regionally or nationally. The committee believes that the interest of state legislatures and private foundations in the endeavors we describe will be kindled and sustained only by a continuing federal presence in the concerns of allied health education and practice. For this reason, the committee makes the following recommendation about the federal leadership: The Department of Health and Human Services should maintain an organizational focal point on allied health personnel to implement the grant programs recommended in this report, to coordinate the recommended work of the interagency data task force (recommended in Chapter 2), and to facilitate communication between state legislative committees and the federal government. REFERENCES Allied Health Education Advisory Committee. 1980. Guiding Concepts for the '80s. CB Study Paper 29. Austin: Coordinating Board, Texas College and University System. Amatayakul, M.K. 1987. Report from the AMRA Manpower Survey. Journal of the American Medical Record Association 58(3):25-36. American Dietetic Association. 1985. A New Look at the Profession of Dietetics, Report of the 1984 Study Commission on Dietetics. Chicago: American Dietetic Association. American Occupational Therapy Association. 1987. Member Data Survey. Interim Report No. 1. Rockville, Md.: American Occupational Therapy Association. American Physical Therapy Association. 1985. The Plan to Address the Faculty Shortage in Physical Therapy Education. Final Report of the Task Force on Faculty Shortage in Physical Therapy Education. Alexandria, Va: American Physical Therapy Association. September. American Physical Therapy Association. 1987. Active Membership Profile Study. Alexandria, Va.: American Physical Therapy Association. Area Health Education Centers Program. 1987. Health Issues Working Group on Health Professions: Program Inventory. Rockville, Md.: Health Resources and Services Administration. February. Astin, A. W. 1985. Minorities in American Higher Education. San Francisco: Jossey-Bass. Bisconti, A. 1981. National and State Profiles of Collegiate Allied Health Education. 1979-80. Hyattsville, Md.: Health Resources Administration. Bleich, M. 1986. Enhancing Opportunities in Science, Mathematics, and Health Professions: An Invitational Conference. Reno, Nev.: Macy Foundation. July. Bleich, M. 1987. Strengthening Support Networks for Minorities in Health Science Careers: A National Symposium. New York: Macy Foundation. January. Booker, N. 1987. Minorities and Allied Health Education. Background paper prepared 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 203 for the IOM Committee to Study the Role of Allied Health Personnel. Washington, D.C. Bowen, D. 1988. Dental hygiene: A developing discipline? Dental Hygiene 62(1):23-24. Broski, D.C., R. E. Olson, and A. A. Savage. 1985. Increasing research productivity in university- based colleges of allied health. Journal of Allied Health 14(1): 160-162. Brown, R. 1987. Perfusionists: A Case Study. Background paper prepared for the IOM Committee to Study the Role of Allied Health Personnel. Washington, D.C. Bureau of Health Manpower, Health Resources Administration. 1979. A Report on Allied Health Personnel. November 26. Washington, D.C.: U.S. Government Printing Office. CAHEA (Committee on Allied Health Education and Accreditation). 1987a. Allied Health Education Directory, 1987, 15th ed. Chicago: American Medical Association. CAHEA 1987b. Voluntary Program Withdrawals from CAHEA Accreditation, 1983-87. Chicago: American Medical Association. CAHEA. In press. Carpenter, H. 1982. Disadvantaged in the Health Resources Administration's allied health training programs: A historical review. Health Resources Administration, Washington, D.C. June. The Circle, Inc. 1987. Revitalizing Pharmacy and Allied Health Professions Education for Minorities and the Disadvantaged. Rockville, Md.: Health Resources and Services Administration. College of Health Deans. 1987. Unpublished survey data. Cooperative Institutional Research Program. 1987. 1987 Freshman Survey Report. Los Angeles: University of California, Los Angeles. Covey, P., and J. Burke. 1987. Research and the mission of schools of allied health. Journal of Allied Health 16(February):1-5. Fitzgerald, L. F., and J. O. Crites. 1980. Toward a career psychology of women: What do we know? What do we need to know? Journal of Counseling Psychology 27:44-62. Flack, H. 1982. Minorities in Allied Health Education. Rockville, Md.: Office of Health Resources Opportunity, Health Resources Administration. August. Freeland, T. E., and M. A. Gonyea. 1985. Financing Allied Health Clinical Education. Report prepared for the Health Resources and Services Administration, Rockville, Md. Garrison, H., and P. Brown 1985. Minority Access to Research Careers: An Evaluation of the Honors Undergraduate Research Training Program. Committee on National Needs for Biomedical and Behavioral Personnel. Washington, D.C.: National Academy Press. Gonzales, C. 1987. Minority Biomedical Research Program. Bethesda, Md.: Division of Research Resources, National Institutes of Health. March. Health Professions Report. 1988. Social work schools' enrollment increases, but trend not universal. Whitaker Newsletters, Inc. (New Jersey) 17(2): 2-5. Health Resources and Services Administration. 1984. An In-Depth Examination of the 1980 Decennial Census Employment Data for Health Occupations: Comprehensive Report. ODAM Report No. 16-84. Washington, D.C.: Government Printing Office. July. Health Resources and Services Administration. 1986. Report to the President and Congress on the Status of Health Personnel in the United States. Rockville, Md.: Health Resources and Services Administration. Health Resources and Services Administration. 1987. Report to Congress on Nursing and Other Health Professions Educational Programs Reimbursed Under Medicare. Rockville, Md.: Health Resources and Services Administration. December. Hedrick, H. 1985. Discontinuation of allied health schools and programs. Is there a pattern? Journal of Alhed Health 14(1): 159-160. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 204 Herr, E. L., and S. Cramer. 1984. Career Guidance and Counseling Through the Life Span. Boston: Little, Brown. Holcomb, J. D., D. W. Evans, W. P. Buckner, and L. D. Ponder. 1987. A longitudinal evaluation of graduate programs in allied health education and administration. Journal of Allied Health 16(2):119-133. Hudson Institute. 1987. Workforce 2000: Work and Workers for the 21st Century. Indianapolis, Ind.: Hudson Institute. June. Institute of Medicine. 1983. Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C.: National Academy Press. Kaminski, G. 1987. Allied Health Study: Two Year College Survey. Unpublished paper. Cincinnati Technical College. King, E. 1985. Articulation of allied health education. Pp. 126-139 in Review of Allied Health Education: 5. J. Hamburg, ed. Lexington, Ky.: University Press of Kentucky. La Jolla Management Corporation. 1984. An Assessment of Preparatory Activities for the Health Careers Opportunity Program: Final Report. Rockville, Md.: Health Resources and Services Administration. Lent, R., S. Brown, and K. Lark. 1986. Comparison of three theoretically derived variables in predicting career and academic behavior: self-efficacy, interest congruence, and consequent thinking. Journal of Counseling Psychology 34(3):293-298. Lewin and Associates. 1987. Hospital Decision-Making About Offering Health Professions Clinical Education Opportunities and the Effects of Payment Policies on These Decisions. Final Report. Rockville, Md.: Health Resources and Services Administration. May. Ludlow, C. L. 1986. The Research Career Ladder in Human Communication Sciences and Disorders. Bethesda, Md.: National Institutes of Health. Malone, P. 1979. Creating New Allied Health Programs: Considerations and Constraints. Atlanta: Southern Regional Education Board. Mandex, Inc. 1987. An Assessment of State Support for Health Professions Education Programs: Final Report. Rockville, Md.: Health Resources and Services Administration. June. Mathematica Policy Research, Inc. 1987. Draft final report on exploration of trends and changes in clinical education in the preparation of allied health professions. Washington, D.C. June 30. Miller, J. D. 1986. Multivariate models to predict the selection of and persistence in a career in the professions. Paper presented to the 1986 annual meeting of the American Educational Resource Association, San Francisco, April 17. Mingle, J. 1987. Trends in Higher Education Participation and Success. Publ. No. MP-87-2. Denver, Colo.: Education Commission of the States and State Higher Education Executive Officers. Missouri Coordinating Board for Higher Education. 1986. Recommendations to the Committee on Academic Affairs regarding "State-Level Review of Existing Programs in Health Sciences Education." Jefferson City, Mo. April. National Commission on Allied Health Education. 1980. The Future of Allied Health Education: New Alliances for the 1980s. San Francisco: Jossey-Bass. New York State Education Department, Bureau of Higher and Professional Education Testing. 1985. Program Guidelines. Albany: New York State Education Department. Newman, F. 1985. Higher Education and the American Resurgence. Princeton, N.J.: Carnegie Foundation for the Advancement of Teaching. Parks, R. B., and H. L. Hedrick, 1988. Program directors' perspectives regarding CAHEA- accredited allied health education. Summary of a 1987 survey. Allied Health Education Directory, 16th ed. Chicago: American Medical Association. 

THE ROLE OF EDUCATIONAL POLICY IN INFLUENCING SUPPLY 205 Perrin, K. L. 1987. Remarks at the Symposium on the Future of Allied Health Education , Susquehanna University, Selinsgrove, Penn., April. Petersdorf, R. G. 1987. A report on the establishment. Journal of Medical Education 621 (February): 126-132. Southern Regional Education Board. 1980. Planning and Designing Allied Health Education for Program Review. Atlanta, Ga. U.S. Department of Health and Human Services. 1985. Report to the Secretary's Task Force on Black and Minority Health. Washington, D.C.: U.S. Government Printing Office. August.