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4 Demand and Supply in Allied Health Fields MAJOR ECONOMIC, DEMOG~PHIC, AND SOCIAL FORCES must be taken into account to assess the directions and magnitude of changes in the U.S. health care system and the implications of these changes for allied health employment. This chapter examines how each of 10 allied health fields is affected by these forces and how they will determine the demand for and supply of personnel for each field by the year 2000. The discussion that follows deals with national trends, even though local decision makers concerned with allied health practitioners may be faced with conditions that differ substantially from the national experience. The committee believes that its national analysis will be helpful to those who must draw conclusions about the future of allied health personnel in their own localities. The committee based its assessment of the future on several types of information. Bureau of Labor Statistics (BLS) projections of demand are the source of quantified demand information which the reader will find throughout this chapter (Bureau of Labor Statistics, 1987~. To draw con- clusions about demand the committee incorporated its own judgments about the impact of the many forces that drive demand. Assessments of supply were based on what would happen if the situation remained un- changed with respect to the rates at which individuals leave and enter the allied health work force. To that assumption were added assessments of the likelihood of the situation remaining unchanged. A final element in trying to foresee the future was the application of our limited knowledge of current demand and supply balances. Because decision makers must act even in the absence of complete data, the committee decided to make 96
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DEMAND AND SUPPLY IN 10 FIELDS 97 assessments of future labor markets for allied health practitioners using BLS data. (Chapter 2 described the BLS data collection and projection process.) The committee advises readers to view the projections critically, in light of their inherent limitations. These projections should be inter- preted not as a precise prediction of the future but rather as indications of the magnitude of change. The tools can then be used as a basis from which local and federal decisions makers can develop their own best esti- mates of the labor market. The committee emphasizes the importance of continued data collection to allow more precise projections. In some allied health fields the committee's assessment showed large discrepancies between demand and supply. The committee is not sug- gesting, however, that these gaps will necessarily occur. Rather, the market will eventually adjust so that a reasonable balance is achieved over time. If employers are sufficiently hard-pressed, they will raise salaries, which will attract more people to allied health careers. Employers whose ability to pass on costs is increasingly limited by prospective payment will also try to increase productivity and reduce the number of workers they employ as those workers become more expensive. Yet the committee is concerned that the market response will not be quick or creative enough to avoid some negative consequences for ex- ample, erosion of the quality of care, service disruptions, and constraints on the ability of providers to make timely investments in new modes of service. Because these are serious consequences, the committee believes that it is important to try to anticipate them well enough in advance to forestall them if possible. Later chapters in this report are devoted to examining ways in which health care provider and educational institutions can protect themselves and, ultimately, patients from the costs associated with imperfectly working markets. The committee's comments about the way the year 2000 will look do not allow for major changes in the ways in which Americans pay for health care. If a major financing change should occur, the future of many allied health fields will be significantly altered. To illustrate the effects of financing changes, the committee applied the scenarios presented in Chapter 3 to each of the 10 allied health fields discussed in this chapter. In assessing future personnel demand for each of the 10 occupations, we have assumed that the current mix of fees for service and prospective payment (i.e., the mixed model scenario) will prevail for the next 12 years. As health care policy decisions are made at the national and local levels, however, planners must adjust their views of future allied health employ- ment. To assist in this process, the committee has indicated how each profession might be affected by incentives characteristic of the access scen- arios (which could include new state Medicaid entitlements or a nationally mandated benefits program) or the prospective payment scenario (which
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98 ALLIED HEALTH SERVICES could include a new state hospital rate commission or the extension of PPS to settings other than acute care hospitals). The committee has also attempted to alert readers to the significant trends in factors influencing supply most often, the number of graduates and the number of educational programs. Yet labor force behavior is equally important. Unfortunately, there are only crude data on entrance into and exit from the allied health labor force; thus, the committee could make only very rough estimates of future supply. What is known is that even small changes in tenure in the work force can have a substantial effect on the future supply of allied health personnel. CLINICAL LABORATORY TECHNOLOGISTS AND TECHNICIANS Demand for Medical Laboratory Technologists and Technicians BLS predicts that between 1986 and the year 2000 the number of clinical and medical laboratory jobs for technologists and technicians will grow from 239,400 to 296,300, an increase of 24 percent. Although the growth rate is below that forecast for many other allied health occupations, it represents a substantial number (57,000) of new jobs. By comparison, the expected dramatic 87 percent increase in physical therapist employment represents only 54,000 new jobs. It must be remembered that the BLS data are based on employers' responses to questions about the numbers of people performing defined tasks. Respondents are not asked to distinguish licensed or certified personnel from those without such credentials. Clinical laboratories are in a period of rapid change. Technological changes are allowing the performance of tests in new settings and are also generating new tests. PPS has caused hospital managers to rethink the relative roles of in-house and reference laboratories. Changes in reimbursement have made physicians seek the benefits of providing office laboratory services. New settings for health care, such as ambulatory centers, are encouraging the establishment of laboratories in nontraditional settings. When analyzing these changes in terms of their impact on the demand for technologists and technicians, it is important to distinguish between changes that reduce demand, changes that increase demand, and changes that make no difference to manoower but only represent a change in location, techniques, or practice style. Because approximately 63 percent of clinical laboratory technicians and technologists are employed by hospitals (Table 4-1), changes in that setting will greatly influence the demand for those personnel and where they work. Indeed, a number of factors that are currently affecting the hospital lab- oratory work load may, in turn, affect personnel needs. ~ 1
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DEMAND AND SUPPLY IN 10 FIELDS 99 TABLE 4-1 Major Places of Wage and Salary Employment for Medical and Clinical Laboratory Technologists and Technicians, 1986 Actual and Projected for the Year 2000 Employment Setting Total employments Total wage and salary employment Hospitals, public and private 149,800 Offices of physicians 30,100 Offices of dentists and other health care practitioners Medical and dental laboratories 28,100 Outpatient care facilities 5,300 Number of fobs, 1986 Percentagea Number of Jobs, 2000 Percentagea 296,300 239,400 238,400 890 100.0 62.8 12.6 0.4 11.8 2.2 295,200 160,000 46,200 1,800 43,200 13,000 100.0 54.2 15.7 0.6 14.7 4.4 aThese percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. tTotal employment = wage and salary employment + self-employment. These figures include 1,000 self-employed workers in 1986 and 1,027 in the year 2000 who are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. The introduction of PPS and the resultant reduction in occupancy rates, as well as the incentives it offers to provide less costly care, all affect hospital laboratories in several ways. Many hospitals have increased their use of reference laboratories for specialized tests, concentrating in-house labo- ratory work on widely used tests for which economies of scale can be achieved. Simultaneously, much preadmission testing is done on an out- patient basis, and the inpatient test mix has changed as more complex cases are admitted. According to the American Hospital Association, full-time- equivalent (FTE) employment in U.S. registered hospitals fell between 1983 and 1986, with medical technologist employment falling by 2.4 percent. FTE employment of other laboratory personnel fell by 5.3 percent between 1983 and 1985 and rose by 2.1 percent in 1986 (Bureau of Health Profes- sions, 1985; American Hospital Association, 1987~. A survey of the early impact of the diagnosis-related group (DRG) system on 122 hospital lab- oratories noted that 63 percent of hospitals experienced increased test volume in 1983. Increases in test volume occurred in only 32 percent of hospitals in 1984. The number of hospitals experiencing decreased test volume almost doubled from 24 percent in 1983 to 44 percent in 1984. The effect of the
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100 ALLIED HEALTH SERVICES decreases on staffing was observable. Fifty-seven percent of laboratories reduced employment after PPS only 4 percent increased employment (Medical Laboratory Observer, 1984~. These early changes that reduced demand did not continue, however. Current utilization and budgets are growing, and staff reductions have abated (Gore, 1987~. Because the hos- pital census is thought to be a less reliable laboratory work load predictor than the severity of patient illness (Harper, 1984), one must look to the patient mix for explanation. With an aging population, the severity of illness is increasing. Although the number of lab items per discharge fell sub- stantially during the early years of PPS, it rose 19.8 percent in 1985. Possible reasons for the upturn include increased case complexity, fewer oppor- tunities to shift care to outpatient settings, and fewer opportunities to eliminate unnecessary services (Prospective Payment Assessment Commis- sion, 1987~. Medicare is not the only payer that is trying to reduce laboratory work. Other payers are becoming increasingly conscious of laboratory costs. For example, in 1987 Blue Cross and Blue Shield issued diagnostic testing . . At- ~ .. guidelines tor the appropriate use of 13 laboratory tests. Some of these tests are routine hospital admission or preoperative tests. While these guide- lin~ Caere not ~C~ri~tr`~ with coverage rules. the recommendations are A 1 1 $ q ~ ~ ~ , ex pected to be adopted by most of the plans and possibly by other insurers (A bramowitz, 19871. Efforts like that of Blue Cross and Blue Shield may herald a move from exhaustive testing to more targeted use of laboratory work. Technological change affects clinical laboratories in all settings. Today, while there is much discussion of automation in the laboratory even ro- botics that may reduce personnel needs or lower the skill levels required, concomitantly, there are potentially offsetting developments of new and complex labor-intensive, nonautomated tests. Technological changes, together with financial incentives and patients' desires, have stimulated physicians to make laboratory services available in their offices. Several surveys have been conducted of the extent of this practice. Estimates of the number of physician office laboratories range from approximately 80,000 to more than 250,000 (American Society for Medical Technology, 19861. BLS estimates that there are 30,100 technol- ogist and technician jobs in physicians' offices, a number that is expected to rise to more than 46,200 in the year 2000. Observers close to the scene . . ~ ~ ~ _ A A A A · ~ · · · ~ · . 1 · ~ 11 1 ~ r~ ~ ~ 1~C ~ _~: perceive ulmlnlshlng enthusiasm ror small pnys~aun I; --I, possibly because they are not proving to be cost-effective and possibly because there are rising expectations of increased regulation to control quality. Two important questions for laboratory personnel demand emerge from the physician office laboratory phenomenon. One is whether physician
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DEMAND AND SUPPLY IN 10 FIELDS 101 office tests are additional tests or substitutes for testing at other sites. An- other is whether physicians employ clinical laboratory technologists or tech- nicians. No evidence exists to answer the first of these questions. On the question of staffing, a literature review concluded that personnel other than technicians and technologists are more likely to do laboratory work in small or solo practices. Often, nurses are used. The larger the practice, the more likely that trained laboratory personnel are employed. One study found that more than 50 percent of group practices employed medical technologists (Frost and Sullivan, Inc., 1985~. However, changes in the staffing of physician office laboratories may be on the way. Under its Omnibus Budget Reconciliation Act of 1987, congress enacted provisions that will require office laboratories that perform more than 5,000 tests on their own patients to conform to the Medicare conditions of participation developed for independent laboratories. This policy is scheduled to become effective in 1990. Technologists in independent practice are finding in- creasin~ emnlovment onnortunities as consultants to ohvsicians who need ~ 1 ~ 1 1 1 ~ . . . . ... . .. . . . . . . . . . . . . help with calloratlon, quality control, test interpretation, more sopnlstlcaten procedures, and management of their office laboratories. Other new sites for laboratory work include HMOs and ambulatory care centers. Although 5,500 such centers are projected to be in operation by 1990, not all will employ highly trained lab personnel. At small centers now, nurses and x-ray technicians often perform routine tests, with cross- training conducted by the facility owner (Baranowski, 19851. The development of HMO laboratories is providing employment op- portunities in a new setting, but this employment site should not be thought of as increasing the demand for personnel. Indeed, in the long run, as HMOs in competitive environments begin to seek new ways to control costs, it is reasonable to speculate that a reduction in demand for laboratory work may be brought about by curtailing superfluous testing. Future demand for clinical laboratory personnel has thus far been dis- cussed as if changes will affect technologists and technicians equally. Whether this will actually be the case is unclear. Although incentives to reduce costs might lead one to expect that employers will seek to use less expensive personnel, at times more highly trained staff can be more cost effective. Similarly, although some technological changes, such as increased auto- mation, may allow employers to expand their use of technicians or on-the- job trained personnel, others will require more highly trained staff. The trend in this field appears to be toward the increased use of higher level personnel with demand for lower level staff strengthened by difficulties in hiring more highly skilled workers. A 1987 survey of the American Society for Medical Technology members reports: "Where hiring has occurred in the past two years... more technologists with the bachelor degree were hired than were clinical laboratory technicians (CLTs). Though some fa- . . .
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102 ALLIED HEALTH SERVICES cilities reported substituting specialists and more advanced personnel for entry-level practitioners, others reported hiring more CLTs and on-the- job trainees (OiTs) to some extent as a result of a shortage of clinical laboratory scientists (CLS) professionals" (Price, 19881. In sum, many of the changes occurring in clinical laboratories involve alternatives in the settings in which testing occurs. Some of these changes are spurred by financial considerations; some are driven by changes in the structure of the health care delivery system. Generally, these changes do not affect the demand for trained personnel in a major way because they do not have significant effects on the numbers or types of tests ordered. Although some extra testing is stimulated by the new settings, not all of the work is being done by clinical laboratory technologists or technicians. A concern about laboratory work that has surfaced in the popular press and that has also been voiced by the professional associations relates to quality. Reports of inaccurate PAP smear readings and false-positive AIDS tests have often focused on the laboratory personnel a focus that could result in increased demand for licensed personnel or in the hiring of more personnel of all kinds to relieve pressures on staff. For the future, downward pressures on test volume caused by payers' attempts to reduce costs will be offset by upward pressures as new tests are developed and the aging population demands more services. Similarly, technological change will cause as much expansion as reduction in demand for trained personnel of all levels. Any growth in the demand for medical and clinical lab technologists and technicians will derive from a general expansion of the health care industry, the aging of the population, and an increase in some specific trends such as increased therapeutic drug monitoring, testing for substance abuse, and AIDS screening. Together, these upward pressures should lead to em- ployment growth at a rate that could even exceed BLS's predicted growth of 24 percent to the year 2000. If either AIDS or drug testing becomes widespread, the demand for clinical laboratory technicians and technolo- gists will increase further. This rate of increase could be reduced if, as is likely, tests eventually become more automated. Factors that would cause demand to change significantly and should therefore be monitored by those attempting to track the employment of clinical laboratory personnel include the following: · policies concerning AIDS screening; policies concerning substance abuse testing; technological change; payers' attempts to control test volumes; quality concerns; and trends in state and federal regulation of laboratory settings.
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DEMAND AND SUPPLY IN 10 FIELDS 103 The three scenarios described in Chapter 3 mixed financing, pro- spective payment, and access—have some straightforward implications for clinical laboratory technologist and technician demand. Under the mixed model, growth in jobs is expected (as described earlier in this chapter)- probably in excess of 24 percent to the year 2000. If prospective payment becomes the dominant model, laboratory testing will come under scrutiny and incentives will ensure that all testing contributes to the clinical man- agement of patients. Technological changes to improve cost-effectiveness and decrease personnel, both in numbers and skill levels, will be adopted. Yet demographic pressures will still exert upward pressures. In sum, de- mand will grow at a slower pace under the prospective payment model than under the mixed financing scenario. If a policy to expand access to health care occurs, additional individuals receiving care will increase the demand for laboratory personnel in all settings. Supply of Medical Technologists and Medical Laboratory Technicians The number of baccalaureate graduates in the field of medical tech- nology has shown a downward trend since the end of the 1970s. In 1986 4,477 medical technologists graduated from accredited programs, a de- crease of 28 percent from 1980. The number of accredited programs for medical technologists also decreased 26 percent over the 10-year period ending in 1986. Hospital-based programs closed most frequently, but clo- sures in general occurred because of budget restrictions, the impact of PPS, a lack of qualified applicants, and a decreased need for laboratory personnel in the program's immediate geographic area (CAHEA, 1985b). During the past 10 years, total certificate medical lab technician programs decreased 69 percent. Yet associate degree medical lab technician programs increased over the 10-year period, and they increased more than four fold from 38 programs to 214 programs. Between 1985 and 1986, how- ever, there was a 5 percent drop (CAHEA, 1987a). The trend in certificate and associate degree personnel (technicians) is less clear than that for technologists. Although the 2,747 technician grad- uates in 1986 represent a 9 percent increase over 1980, graduations peaked at nearly 4,000 in 1984 and show a downward trend since then. There are two routes to becoming a technician. One is graduation from a certificate program. Only 817 medical laboratory technicians graduated from certifi- cate programs in 1986, 24 percent fewer than in 1981. The other route is through associate degree programs, from which the number of graduates (1,930) in 1986 was an increase of 11 percent over those graduating in 1981 (CAHEA, 1987a).
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104 ALLIED HEALTH SERVICES At the start of this study, anecdotal evidence from educators and others pointed to a surplus of clinical laboratory technicians and technologists. But during site visits and discussions with knowledgeable observers toward the middle of 1987, the committee began to hear of managers who were having trouble hiring staff for clinical laboratories. Other reports confirm this change (Meyer, 1988), and other evidence supports the suggestion that the labor market is getting tighter. A recent survey of the directors of accredited education programs shows that between 1981 and 1986 the percentage of directors who considered the job market for laboratory tech- nicians and technologists to be attractive increased substantially (Parks and Hedrik, 19881. An informal survey by the American Society for Medical Technology found 54 percent of constituent societies reporting an under- supply of clinical laboratory technologists. The undersupply figure was 38 percent for technicians (Meyer, 19881. A study commissioned by the Health Resources and Services Administration noted that shortages of medical technologists are occurring in some locales (Mathematica Policy Research, Inc., 1987~. Statewide surveys in North Carolina (North Carolina Area Health Education Centers Program, 1987b) showed the vacancy rates for clinical laboratory staff increasing from 4.6 percent in 1981 to 16.5 percent in 1986. However, the salaries of technologists and technicians employed in hospitals between 1981 and 1986 increased 24 and 21 percent, respec- tively. Yet this increase is small compared with 18 other types of hospital employees of these employees, only engineering technicians had an in- crease smaller than 21 percent (University of Texas Medical Branch, 1985, 1987~. These figures suggest that the difficulties in hiring noted earlier in this paragraph may not have been evident in 1986. Conclusion Making statements about the likelihood of future balances or imbalances between the demand for and supply of clinical laboratory personnel is complicated by the multiple routes of entry into laboratory work. Labo- ratory workers may have 4 or more years of postsecondary education, or they may qualify for a job through a combination of shorter educational programs plus experience. Baccalaureate-prepared technologists need less supervision than other personnel, and they may hold a variety of higher level positions for example, laboratory director, manager, consultant, and education coordinator for hospital schools. Technicians may have 2-year associate degrees or combine education and experience to become certified through a professional organization. Other laboratory workers are certified in special areas (e.g., cytotechnology or hematology), and still others may have specialist certification in such disciplines as blood banking or micro- biology. Finally, there are large numbers of uncertified workers as indicated by the discrepancy between the BLS job count and the number of certified
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DEMAND AND SUPPLY IN 10 FIELDS 105 personnel. These multiple routes of entry into a career in clinical labora- tories make it difficult to assess the future supply of laboratory workers. Taking into account the comparatively modest expected growth in new jobs, and assuming that work force behavior and staffing patterns will not change radically, graduations from clinical laboratory programs should be sufficient to keep demand and supply in reasonable balance to the year 2000 if the rate of graduation is sustained at a minimum at its current level. The recent decline in the number of graduates must be halted, however. If this decline should continue, some improvements in salary and working conditions can be expected to bring supply and demand into balance. A number of factors make prognostications in this area tentative. If the growing numbers of biomedical technology firms become major users of laboratory personnel, thus diverting trained personnel from clinical laboratories, salaries and benefits would improve as employers compete for trained personnel. If personnel trained in such disciplines as chemistry and microbiology are no longer available to medical laboratories, there could be problems because these personnel are used to fill jobs when the labor market is tight. A significant change could come about as a result of employers using personnel differently. (For instance, laboratory managers may choose to substitute one level of personnel for another.) A great deal of flexibility is possible. Today, there is sometimes little or no differentiation in the way technologists and technicians are used, a situation that could change. If a 4-year degree becomes mandatory for licensure and licensure becomes a more widespread requirement, the de- mand and supply balance could be severely disrupted. There is increasing debate concerning the advantages and disadvantages of licensure whose purpose is to differentiate jobs according to academic qualifications. The scope of this study did not admit of a conclusion on this matter. As a final note, the clinical laboratory labor market seems to adapt rapidly to change—for example, changes in health care financing incentives. In the course of this study the reports of graduates having a hard time finding jobs were succeeded by reports of shortages of personnel. The reasons given for this turnaround are varied. Laboratories may have allowed staffing levels to decline too far in an overresponse to prospective payment. Laboratory volume may have risen faster than the supply. Others say that the level of stress at the work site has increased because of pro- ductivity pressures and the increased complexity of care. Fear of AIDS adds to the stress, and salaries are not high enough to compensate for such stress; consequently, people are leaving the field (Meyer, 19881. If these factors do generate an increase in the separation rate of workers from the labor force, it would have a significant negative impact on the supply of clinical laboratory technologists and technicians and necessitate greater market adjustments.
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106 ALLIED HEALTH SERVICES DENTAL HYGIENISTS Demand for Dental Hygienists BLS estimates that in 1986 there were 86,700 jobs for dental hygienists. By the year 2000 this number is expected to have increased by 63 percent to 141,000 jobs. Such rapid growth is based on several considerations. First, BLS analysts consider employment growth in dental offices to be the most important element in generating jobs for dental hygienists because the vast majority (97 percent in 1986) is employed in that industry sector (Table 4-21. The BLS projection for dental hygienist employment is hampered by data collection problems that apply only to this sector. The survey on which the BLS data are based was sent to incorporated businesses only. A high proportion of dentists are not incorporated and therefore were not in- cluded in the survey. Dentists' offices provided nearly 460,000 jobs in 1986; this number is projected to reach 706,000 by the year 2000, a 53 percent increase. Con- tributing to this projected expansion is the BLS expectation that the number of working dentists will substantially increase by the year 2000 (from 151,000 to 196,000, almost 30 percent compared with 19.2 percent for all occu- pations). Moreover, these dentists are expected to sustain their level of use of dental hygienists. BLS analysts also believe that the entrance into the dental profession of younger dentists, who are taught how to make effective use of hygienists, will cause a slight increase in the ratio of hygienists to total dentist office staff. Other assumptions on which BLS has based its high-growth prediction include the continued spread of dental insurance, which will generate fur- ther demand for dental services; the aging population's need for dental TABLE 4-2 Major Places of Wage and Salary Employment for Dental Hygienists, 1986 Actual and Projected for the Year 2000 Employment Setting Total employments Total wage and salary employment Offices of dentists Number of lobs, 1986 Percentagea Number of lobs, 2000 Percentagea 14 1 ,000 86,700 86,700 1 00.0 84,300 97.3 14 1 ,000 1 00.0 1 37,300 97.4 aThese percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. Total employment = wage and salary employment + self-employment. Self-employed persons are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.
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148 ALLIED HEALTH SERVICES outside the health care system. In 1986 only 28.6 percent of speech-lan- guage pathologist and audiologist jobs were in the health care services industry. Sixty-four percent were in educational services a sector in which BLS expects demand to be close to stagnant (Table 4-111. Between 1986 and the year 2000, speech-language pathology and audiology jobs in the education sector are expected to increase by only 14 percent. ASHA notes that 13.6 percent of speech-language pathologists and audiologists report that they run their own practices or are independent contractors (American S p e e c h - L a n g u a g e - H e a r i n g A s s 0 c i a t i 0 n , 1 9 8 8 ~ . BLS analysts caution that their classification of speech-language pa- thologists and audiologists includes those prepared only to the bachelor's degree level. These practitioners are not certified by ASHA, which certifies at the master's degree level and above, and thus cannot work in the 36 states with licensure requirements. BLS analysts believe that most non- ASHA-certified personnel are employed in educational services by state education departments in states that certify individuals who have only a bachelor's degree or who lack other qualifications for ASHA certification. TABLE 4-11 Major Places of Wage and Salary Employment for Speech-Language Pathologists and Audiologists, 1986 Actual and Projected for the Year 2000 Employment Setting Number of lobs, 1986 Percentagea Number of Jobs, 2000 Percentagea 60,600 Total employments Total wage and salary employment Educational institutions, public and private Hospitals, public and private Outpatient care facilities Nursing and personal care , - ... . taalltles Offices of physicians Offices of other health care 45,100 42,100 27,000 4,400 2,700 1,200 1,800 00.0 64.0 10.4 6.4 2.7 3.6 56,500 30,800 5,600 4,400 1,900 2,900 00.0 54.62 9.9 7.7 3.4 5.2 practitioners 1,200 2.7 4,400 7.7 aThese percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. tTotal employment = wage and salary employment + self-employment. These figures include 3,000 self-employed workers in 1986 and 4,096 in the year 2000 who are not allocated by place of employment. Offices of health care practitioners other than physicians (including osteopaths) and dentists. The figures include offices of speech-language pathologists and audiologists. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.
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DEMAND AND SUPPLY IN 10 FIELDS 149 There is considerable support for the BLS estimates. Although speech- language pathologists and audiologists may see new opportunities for em- ployment growth under the 1986 Education of the Handicapped Act (which increased the demand for these professionals by funding programs for young children), total employment growth in the education sector will be relatively slow. New employment opportunities will occur in other settings, however. Speech-language pathologists and audiologists are well posi- tioned to benefit from changes occurring in the health care system. Their lesser dependence on hospital employment (which accounted for only 10 percent of jobs in 1986) makes them less vulnerable to any squeeze on employment in that sector. Their reimbursement status positions them to benefit from shifts to care outside of hospitals. Under the Omnibus Budget Reconciliation Act of 1980, a speech-language pathologist may develop a plan of care for patients referred by a physician and be reimbursed by Medicare. Prior to 1980 the amount, duration, and scope of services had to be specified by the physician. Since 1986 speech-language pathology has been included among the therapies that together must be provided for a total of 3 hours per day for a beneficiary to be eligible for Medicare coverage in an inpatient rehabilitation facility. While this could provide an impetus to increased demand for speech-language pathologists, it could also be short-lived as Medicare seeks ways to find an equitable reimburse- ment system that includes cost-control incentives. Medicare will also reim- burse for home care visits, a provision that positions therapists to care for the growing population of patients discharged from hospitals or in need of long-term home care (American Speech-Language-Hearing Associa- tion, 1987b). According to the Health Care Financing Administration the estimated number of speech-language pathologists employed by Medicare- certified home care agencies grew from 303 in 1983 to 5,503 in 1985; the figure dropped to 3,113 in 1986 (American Home Care Association, 19871. The extent to which this drop is due to increased contracting for services or other arrangements is not known. Approximately 48 percent of free- standing home health agencies offer speech-language and audiology ser- vices (American Speech-Language-Hearing Association, Task Force on Home Care, 1986~. Although only a minority of speech-language pathologists and audiol- ogists are employed in hospitals, their use in that setting has not been constrained by PPS. Indeed, between 1983 and 1985 their FTE employ- ment in hospitals increased by 21 percent from 2,684 to 3,252. Committee site visits uncovered several possible reasons for this increase. One is ex- panded speech and hearing coverage by HMOs. Audiology personnel working in hospital outpatient areas are finding that HMO patients are covered for the full range of diagnostic testing and hearing aids. (Previously, commercial insurance subscribers were covered for only a narrow range
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150 ALLIED HEALTH SERVICES of hearing testing.) Speech-language pathologists also cited a growing demand for services for stroke and head-injured patients whose survival rates have improved with the advent of new knowledge and technology. Audiologists noted a growing incidence of hearing defects in young people who listen to music through headphones. Both occupations cited the grow- ing numbers of elderly patients using their services plus an increasing understanding of their work by physicians that has resulted in more nu- merous referrals. In sum, speech-language pathologists and audiologists in their major employment setting educational institutions—are not likely to experience rapid increases in demand. In health care settings, they are positioned for steady growth. Reimbursement allows them to take advantage of the shift to nonhospital care in many settings. Given the expected slow growth in education and faster growth in health care settings, the overall moderate growth predicted by BLS seems reasonable. Factors to be monitored by those wishing to track future demand for speech-language pathologists and audiologists include the following: · Medicare reimbursement of rehabilitation services; · school system growth and financing; · patterns of specific diseases and treatment such as stroke, head trauma, and deafness in youth; and · growth in independent practice opportunities and contractual ar- rangements with freestanding speech-language pathology and audiology . . Organlzatlons. The way in which the three scenarios described in Chapter 3 play out for speech-language pathology and audiology is largely determined by the pattern of employment across the various health care settings and outside the health care system. Scenario 1: The Mixed Model With this scenario, speech-language pathologists and audiologists would be in steady demand as their services were included in comprehensive HMO benefit packages and increasing numbers were needed to work in the less productive home care environment. The demand for rehabilitation and outpatient services would also show steady growth. Scenario 2: Prospective Payment Because only a small proportion of speech-language pathologists and audiologists work in hospitals, the impact of increased prospective payment in this setting would have little impact on total demand. Similarly, bringing
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DEMAND AND SUPPLY IN 10 FIELDS 151 rehabilitation services under prospective payment would result in only a small reduction in overall demand. Outpatient care would show overall growth, but speech-language pathology and audiology would not benefit greatly because these services would be seen as less vital than others that related more directly to physical health. Less vital services would be most vulnerable to reduction under prospective payment. Combining the slight growth in outpatient demand with the reduction in inpatient demand would yield stagnant total demand from the health care sector under this scenario. Scenario 3: Access Speech and hearing deficits are among the group of health problems that are likely to go unserved if individuals experience financial barriers to health care. Under this scenario, those financial barriers would be low- ered and previously ignored communicative deficits would receive atten- tion, stimulating greater demand for speech and hearing services in inpatient . . . and outpatient settings. Supply of Speech-Language Pathologists and Audiologists In 1986 304 programs offered degrees in communication sciences and disorders. Of these programs, 21 percent offered only undergraduate de- grees. The total number of programs has been quite stable since 1983, ranging between 293 and 304 (Cooper et al., 19871. The number of bach- elor's degrees awarded has declined since 1981 by 15 percent to 4,300. The decline was confined to only 2 years, however. The latest figures show an upturn (CAHEA, 1987a). The picture for master's degrees is a little clearer: the number of degrees awarded since 1982 has remained relatively stable. Yet this trend must be viewed together with that for bachelor's degree graduates (Cooper et al., 1987~. Approximately 90 percent of master's degree graduates in speech pathology and audiology have undergraduate degrees in the same disci- plines. Furthermore, the number of master's degree graduates closely matches the undergraduate degrees in speech and audiology with a 2-year time lag (Cooper et al., 19874. It seems reasonable to conclude that most speech- language pathology or audiology undergraduates move on to a speech- language pathology or audiology master's degree and that bachelor's de- gree graduates are the pool from which therapists are drawn. Consequently, we must consider undergraduate as well as graduate degrees as an indicator . . of future supply. The committee is not aware of any evidence that demand and supply are not currently in balance in this field. Although committee members
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152 ALLIED HEALTH SERVICES occasionally heard that rehabilitation facilities were experiencing difficulties in filling vacancies for speech-language pathologists, they also heard that some independent practitioners were unable to generate enough business and were returning to employment in other facilities. Such comments were rare, however, and do not disturb the overall picture of an adequate current supply of practitioners. A national survey of starting salaries for speech- language pathologists in hospitals shows an increase of 23 percent between 1981 and 1986. This increase was lower than that for 17 of 19 other types of personnel. The 33 percent increase for audiologists, however, was higher than that of pharmacists and nurses who are thought to be in short supply (University of Texas Medical Branch, 1981, 1986~. These data indicate a difference in demand for the two types of practitioners but are not in themselves sufficient evidence on which to base a judgment of the markets. Conclusion If baccalaureate graduations remain at approximately the level of the last few years and if most of these graduates go on to master's degrees in speech-language pathology or audiology, there should be a continued balance between demand and supply through the year 2000. This statement implies that significant changes in the rate of salary growth or major im- provements in the conditions of employment should not be expected. How- ever, the production of baccalaureate graduates should be carefully monitored. The data to this time do not indicate whether a downward trend is beginning to develop. If a decline does occur, employers who feel the impact of the drop will need such factors as higher salaries to influence people to pursue careers in language and hearing disorders. CONCLUSION This chapter applies the best available data to assess how the forces that drive the demand for and supply of allied health personnel will affect allied health labor markets. The committee's intention is to alert decision makers to the kinds and magnitudes of market adjustments that they should expect and encourage to sustain a long-term balance between allied health per- sonnel demand and supply. For some fields (e.g., physical therapy, radiologic technology, medical record technology and administration, and occupational therapy), we fore- see a need for decision makers to use the mechanisms under their control to improve the working of the market so that severe imbalances in demand and supply may be prevented. Employers are already concerned about difficulties in hiring in some of these fields, and there are signs that health
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DEMAND AND SUPPLY IN 10 FIELDS 153 care providers are beginning to find some painful as well as some beneficial ways to accommodate new realities. The committee is concerned that in- action may have consequences that would have deleterious effects on the level of health care. For some other fields (e.g., clinical laboratory technology and dental hygiene), there are factors that could cause instability in both demand and supply. For these fields the market is more likely to make the needed adjustments, and serious disruptions are less likely to occur. Yet there are unresolved issues in both of these fields concerning the match between tasks and levels and types of education. The way these issues are resolved could determine whether major imbalances will occur. The demand for and supply of speech-language pathologists, audiol- ogists, respiratory therapists, and dietitians are expected to be sufficiently well balanced for the labor market to make smooth adjustments. The kinds of incremental adjustments that make careers attractive and the ways in which personnel are deployed appear likely to remain in a state of equi- librium over time. Nevertheless, changes in the factors the committee has identified as having major effects on demand and supply could cause disequilibrium. These factors should be monitored. These conclusions about the future outlook refer to the long term. For all fields, there are likely to be periods of greater and lesser imbalance between now and the year 2000. It is the nature of markets eventually to adjust to change. Projected imbalances in demand and supply do not mean that shortages or surpluses will occur. Rather, they signal that employers and potential employees must and probably will make adjustments. Only rarely are markets unable to accommodate changes in demand and supply through a variety of adjust- ment mechanisms. We have identified areas for potential adjustment in both demand and supply, which forms a basis for understanding future policy directions concerning supply and use of allied health personnel. The objective of policy is to make the process of adjustment less painful and less costly. Decrements in quality of care, interruptions or reductions of service, and curtailment of investment in new technologies and organizational forms (such as home care or HMOs) that might improve the efficiency of health care delivery are all possible by-products of personnel shortages. Any de- cision to intervene in the labor market is made through the political process and reflects society's willingness or unwillingness to tolerate painful dis- locations. In many industries, such dislocations are viewed as normal and acceptable. Public policy actions have demonstrated that health care is viewed differently. The next three chapters of this report describe what educators, employers, and regulators, together with government, can do to facilitate the smooth working of the market.
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DEMAND AND SUPPLY IN 10 FIELDS 157 Lucash, P. 1983. EMS volunteers: Facing the challenges of the '80s. Journal of Emergency Medical Services, October:41-45. Mathematica Policy Research, Inc. 1987. Exploration of Trends and Changes in Clinical Education in the Preparation of Allied Health Professions. Princeton, Ad.: Mathe- matica Policy Research, Inc. tune. McKay, I. I. 1985. Historical review of emergency medical services, EMT roles, and EMT utilization in emergency departments. Journal of Emergency Nursing 11(1):27-31. McMahon, E. M. 1986. Approval of a proposal to establish an associate degree in applied science in dental hygiene at the Community College of Rhode Island. Memorandum. State of Rhode Island Office of Higher Education, Providence. December 5. Medical Laboratory Observer. 1984. The impact of DRGs after year 1: First steps toward greater lab efficiency. December:33-38. Meyer, D. M. 1988. The president speaks. ASMT Today 3(1):3. National Association for Home Care. 1987. Unpublished data. National Association for Home Care, Washington, D.C. National Emergency Medical Services Clearinghouse. 1985. State Emergency Medical Ser- vices Personnel Training. The 1985 National EMS Data Summary. Lexington, Ky.: The Council of State Governments. National Institute on Aging. 1987. Personnel for health needs of the elderly through year 2020. U.S. Department of Health and Human Services, Washington, D.C. September. North Carolina Area Health Education Centers Program. 1987a. 1986 Allied Health Man- power Surveys: Summary Report. Chapel Hill, N.C.: North Carolina Area Health Education Centers Program. August. North Carolina Area Health Education Centers Program.1987b.1986 Medical Technology Manpower Survey: Final Report. Chapel Hill, N.C.: North Carolina Area Health Education Centers Program. August. North Carolina Area Health Education Centers Program. 1987c. 1986 Occupational Ther- apy Manpower Survey: Final Report. Chapel Hill, N.C.: North Carolina Area Health Education Centers Program. August. North Carolina Area Health Education Centers Program. 1987d. 1986 Radiologic Tech- nology Manpower Survey: Final Report. Chapel Hill, N.C.: North Carolina Area Health Education Centers Program. August. Packer, C. L. 1985. Automation in the medical records department. Hospitals 59(5): 100- 104. Parks, R. B., and H. L. Hedrick. 1987. Program director perspectives on student and employment characteristics. Committee on Allied Health Education Accreditations, American Medical Association, Chicago. Petty, T. L.1986. Rational respiratory therapy. New England Journal of Medicine 315(5) :317- 319. Price, G. 1988. ASMT Survey II shows strong nonphysician purchasing consulting roles. ASMT Today 3(1):3-4. Prospective Payment Assessment Commission. 1987. Technical Appendixes to the Report and Recommendations to the Secretary, U.S. Department of Health and Human Services. Washington, D.C.: Prospective Payment Assessment Commission. April 1. Schraffenberger, L. A. 1987. The Impact of Prospective Payment on Medical Record Practitioners: A Follow-Up Study in 1986. Chicago: American Medical Record As- . . soclatlon. Scott, S. I. 1987. Medicare extends coverage. July 1; HCFA issues interim instructions. OT Week 1(25): 1. Shewan, C. M. 1987. An Update on Supply Estimates for Speech-Language-Hearing Personnel. Unpublished paper, American Speech-Language-Hearing Association. Rockville, Md.
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158 ALLIED HEALTH SERVICES Smith, J. P., and B. I. Bodai. 1985. The urban paramedic's scope of practice. Journal of the American Medical Association 253(4):544-548. Solomon, E. 1988. Trends in dental education. Paper presented by the American Asso- ciation of Dental Schools at the IOM meeting, "Roles and Training of Health Profes- - sions," Washington, D.C. Steinberg, E. P. 1985. The impact of regulation and payment innovations on acquisition of new imaging technologies. Radiologic Clinics of North America 23(3):381-389. University of Texas Medical Branch. 1981. 1981 National Survey of Hospital and Medical School Salaries. Galveston: University of Texas. December. University of Texas Medical Branch. 1986. 1986 National Survey of Hospital and Medical School Salaries. Galveston: University of Texas. November. Veterans Administration, Office of Personnel and Labor Relations. 1987. Report of 1986 Survey of Health Occupational Staff. Washington, D.C.: Veterans Administration. March 27. Whitlock, E., and J. Whitmore. 1987. A report from the American Medical Record As- sociation: Non-management positions. American Medical Record Association, Chi- cago. June.
Representative terms from entire chapter: