The Impact of Workforce Shortages on Cost, Quality and Access: How Should We Respond Edward Salsberg Executive Director Center for Health Workforce Studies.

The Impact of Workforce Shortages on

Cost, Quality and Access:

How Should We Respond

Edward SalsbergExecutive Director

Center for Health Workforce StudiesSchool of Public Health, University at Albany

http://chws.albany.edu

State Long Term Care Programs:

Balancing Cost, Quality and Access

Indianapolis, Indiana

May 7, 2002

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The Center for Health Workforce Studies School of Public Health,

University at Albany, SUNY

Dedicated to studying the supply, demand, use and education of the health workforce

Committed to collecting and analyzing data to understand workforce dynamics and trends

Goal to inform public policies, the health and education sectors and the public

One of five regional centers with a cooperative agreement with HRSA/Bureau of Health Professions

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Overview of Presentation

A. Crisis as opportunity

B. Overview of the health workforce

C. The long term care paraprofessional workforce

D. Approaches to responding to health workforce shortages

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Crisis as Opportunity:The Crisis

Serious shortages threatening ability to deliver services

The squeeze-few new dollars and the high cost of more workers

Concerns with medical errors and quality Worker and management dissatisfaction Buried in paperwork and regulation Racial and ethnic imbalances Decreased interest in health careers

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Where are the Shortages? Direct care workers, including home

health aides and nursing home aides Registered nurses Radiologic technicians Pharmacists Lab/medical technologists Dentists Information system specialists Medical coders

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The Health Workforce: A Basic Premise

A health care system is only as good as its workforce

The workforce directly impacts on quality, cost and access

System wide high turnover, difficulty recruiting and worker dissatisfaction are signs of a systemic problem

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Factors Contributing to Health Workforce Shortages

Short term factors Competition for workers and full economy Educational system response lags Demand rising

Long Term Demographic factors The aging of America: increase in demand for

health services The aging of America: decrease supply of

workers Changing racial/ethnic mix Career choices for women

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Factors Contributing to Health Workforce Shortages, continued

Workplace factors Physically and emotionally demanding

work Non-competitive wages and benefits Job design and working conditions Paperwork and lack of information

systems Poorly trained managers

Shortages Quality of Care

Job Design-Working

Conditions

PoorlyTrained

Managers

WorkerDissatisfaction/

Turnover

Lack of Information

Systems/Paperwork

Lack ofDiversity

Limited Investment

inTraining/Education

Lags in Education

Rising Demand

Aging

Competition

Wages & Benefits

Demographics

Factors Impacting on Shortages

Factors Impacting on Shortages and Quality

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The Health Care Workforce

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More Than 1 in 10 Americans Works in Health Care or is a Health Professional

Health Professiona

ls

Other Workers

Total

Health service setting

8,642,749 4,098,331 12,741,080

Other work settings 2,167,418 126,649,685

128,817,103

Total 10,810,167 130,748,016

141,558,183

Health professionals working in health service settings

8,642,749 6.1%

Health professionals working in other settings 2,167,418 1.5%

Other workers in health service settings 4,098,498 2.9%

US health workforce 14,908,498 10.5%

US civilian labor force 141,558,183

100.0%

4.1 million other

workers

8.6 million health

professionals

2.2 million health

professionals

Health professions & Occupations

Health service settings

Bureau of Labor Statistics, 2001Figures shown are the average of 12 months’ data (October 2000 – September 2001)

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Demographics of the Health Workforce: Gender

Clinical laboratory technologists and technicians 75%Dental hygienists 99%Dietitians 90%Health records technologists and technicians 89%Occupational therapists 91%Radiologic technicians 69%Registered nurses 94%Respiratory therapists 61%Social workers 73%Speech therapists 93%

Total resident population 51%

Notes: Figures presented for professions are annual averages & include civilian labor force only.

Sources: Bureau of Labor Statistics, Census Bureau. Current Population Survey - Basic Monthly, 2000; Census Bureau, U.S. Population Estimates by Age, Sex, Race, and Hispanic Origin: 1980 to 1999 (Civilian noninstitutional population -- with

Percent female, 2000

short-term projections to dates in 2000); National Sample Survey of Registered Nurses

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Demographics of the Health Workforce: Age

Median age 1989 1999Change 1989-

1999

Clinical laboratory technologists and technicians 34.3 38.0 + 3.7Dental hygienists 32.7 37.7 + 5.0Dietitians 38.3 40.0 + 1.7Health records technologists and technicians 35.3 40.3 + 5.0Occupational therapists 33.3 37.0 + 3.7Radiologic technicians 34.3 38.0 + 3.7Registered nurses 37.3 42.7 + 5.4Respiratory therapists 32.3 38.0 + 5.7Social workers 38.7 40.3 + 1.7Speech therapists 35.7 40.7 + 5.0

Total civilian labor force 35.7 38.7 + 3.0

Source: Bureau of Labor Statistics, Current Population Survey - Annual Demographic Supplement, 1988-2000.Notes: Figures presented are averages of three years' data. Civilian labor force only.

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Demographics of the Health Workforce: Race/ethnicity

Non-Hispanic

white

Non-Hispanic

BlackAmerican

Indian

Asian & Pacific

Islander Hispanic

Clinical laboratory technologists and technicians 67% 18% 1% 7% 8%Dental hygienists 96% 2% 0% 0% 2%Dietitians 71% 19% 0% 5% 5%Health records technologists and technicians 73% 18% 0% 7% 1%Occupational therapists 88% 3% 0% 3% 6%Radiologic technicians 80% 11% 0% 1% 8%Registered nurses 87% 5% 1% 4% 2%Respiratory therapists 80% 12% 0% 3% 5%Social workers 66% 23% 1% 2% 9%Speech therapists 94% 4% 0% 0% 2%

Total resident population 71% 12% 1% 4% 12%

Notes: Figures presented for professions are annual averages & include civilian labor force only.dates in 2000); National Sample Survey of Registered Nurses

Sources: Bureau of Labor Statistics, Census Bureau. Current Population Survey - Basic Monthly, 2000; Census Bureau, U.S. Population Estimates by Age, Sex, Race, and Hispanic Origin: 1980 to 1999 (Civilian noninstitutional population -- with short-term projections to

Race/ethnicity, 2000

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Growth Between 1990 and 2000 and Projected Growth 2000 – 2010 Health Care Occupation and Non-Health Care Employments

25.8%28.8%

18.7%

14.1%

0%

10%

20%

30%

1990 - 2000 2000 - 2010

Health Care Occupations Non-Health Occupations

Data Source: Bureau of Labor Statistics, Occupational Employment Projections to 2010Monthly Labor Review , November 2001

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Health Care Occupations Forecast to Grow the Most from 2000 to 2010

2000 2010Registered nurses 2,194 2,775 25.6 1,004Nursing aides, orderlies, and attendants 1,373 1,697 23.5 498Home Health Aides 615 907 47.3 370Personal and home care aides 414 672 62.5 322Licensed practical and licensed vocational nurses 700 842 20.3 322Medical assistants 329 516 57.0 274Physicians and surgeons 598 705 17.9 196Dental Assistants 247 339 37.2 136Medical and health services managers 250 330 32.3 123Pharmacy technicians 190 259 36.4 118

Occupation

Total job openings due to growth and net

replacements, 2000-10 (thousands)

Percent Change

Number (thousands)Employment

Source: Bureau of Labor Statistics: Occupational Employment Projections to 2010 Page 1 of 2 Monthly Labor Review, Nov 2001

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Long Term Care Paraprofessionals

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Nurse Aides and Personal Care Workers comprise 38% of the Nursing Home EmployeesNursing & Personal Care Facility Employment by Occupation, US, 1998

Non-health professions

33%

Personal care, home health & nursing aides

38%

Other health professions

8%

LPNs11%

RNs9%

Social workers1%

Source: Bureau of Labor Statistics.

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Home Health Aides and Personal Care Workers comprise Half of All Home Care Workers and RNs are Nearly 20%Home Health Care Services Employment by Occupation, US, 1998

Non-health professions

16%

Personal care, home health & nursing aides

50%

Other health professions

7%

RNs19%

LPNs6%

Physical therapists2%

Source: Bureau of Labor Statistics.

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Demographics of the Long Term Care Paraprofessional Workforce: Age

36.4

42.838.0

05

1015202530354045

Nursing homeaides

Home careaides

Hospital aides

Mean Age

Source: Current Population Survey 1997 – 1999

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Demographics of the Long Term Care Paraprofessional Workforce: Education

0%5%

10%15%20%25%30%35%40%45%50%

<HS HS grad Somecollege

College 4 yrs+

Education

Nursing home aides Home care aides Hospital aides

Source: Current Population Survey 1997 – 1999

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Demographics of the Long Term Care Paraprofessional Workforce: Race

0%

10%

20%

30%

40%

50%

60%

70%

80%

White Black AmericanIndian/Eskimo

Asian/PacificIslander

Race

Nursing home aides Home care aides Hospital aides

Source: Current Population Survey 1997 – 1999

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A Conceptual Framework for State Responses to Workforce Shortages

1. Expand pipeline: education and training strategies (supply Side)

2. Improve retention: job related strategies (supply side)

3. Reduce numbers needed: improve productivity/reduce paperwork (demand side)

4. Other strategies

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1.A Expanding the Pipeline:Educational Strategies

Scholarships and loan repayment Grants for faculty, expansion or start up High school health careers awareness Marketing health careers/public service

announcements Capitation funding and/or mandates for

educational programs Support for efforts to increase minority

recruitment and retention Support for education demonstrations and

development, i.e. distance learning, computer assisted learning

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1.B Expanding the Pipeline: Other Strategies

Studies and reports Increased reimbursement/higher

wages State funding for training initiatives

TANF Medicaid State dollars

Building Career Ladders Nurse Aide to LPN LPN to RN

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2. Improving Retention and Job Related Strategies

Best practices conferences on job design and retention

Reimbursement support for higher wages

Fund demonstrations to improve working conditions and redesign jobs

Reimbursement and grants to encourage improved benefits for workers, i.e. health insurance, portable benefits within industry

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2. Improving Retention andJob Related Strategies (cont’d)

Encourage and support management and supervisor training

Support technology that supports workers

Support for career ladders Prohibit mandatory overtime ???? Mandate minimum staffing ratios ????

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3. Modify Demand and Improve Productivity

Dissemination of information/best practices conferences on efficient and productive care

Regulatory changes on scope of practice and use of workers

Modify health facility requirements Explore ways to reduce paperwork Demonstrations and evaluation on job

redesign Aggressively promote technology to support

efficiency and effectiveness Collect and analyze data on staffing and

productivity

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4. Other Responses to Shortages

Task forces, commissions, and committees

Support for family/informal care givers

Better data collection and needs assessments

Support for or opposition to increased immigration

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The AHA Health Workforce Commission

In Our Hands:

How Hospital Leaders Can Build a Thriving Workforce

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“In Our Hands-How Hospital Leaders Can Build a Thriving Workforce”

• 5 Sets of Recommendations: Foster meaningful work Improve the workplace

partnership Broaden the base Collaborate with others Build societal support

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Ten Recommendations for States to Address Workforce Shortages and Improve Quality

1. Assure competitive wages and benefits2. Invest in worker education and training3. Use Medicaid reimbursement to

support workforce development4. Support demonstrations and

evaluations related to both job design and education and training strategies

5. Support health and education sector partnerships

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Ten Recommendations to Address Workforce Shortages and Improve Quality, continued

6. Support career ladders7. Support efforts to increase

diversity of the workforce8. Support efforts to improve

management and supervisory skills

9. Support for family care-givers10. Support technologies that assist

workers

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Crisis as Opportunity:The Opportunity

An adequate supply of health workers Increased worker satisfaction Better quality of care A more effective delivery system More cost effective care Information systems that work A more culturally diverse workforce