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1
The robustness of the healthcare workforce
David Auerbach, PhD
External Adjunct Faculty Member, Montana State University
Director of Research, Massachusetts Health Policy Commission
With help from: Peter I Buerhaus, PhD and Douglas O Staiger, PhD
2
The health care workforce in 2016
Home Health and personal care aides ($22k) Nursing aides ($27k) Med asst($32k)
Physicians $220k
Pharm$122k
PT$85k
Registered Nurses ($68k)Lab Tech $51k
Lic PractNurse($44k)
Physician Assistants$101k
Nurse Practitioners$108k
Master’s/Doctoral
Associate’s /Bachelor’s
High School +
Educational level
Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million.Sources: Bureau of Labor Statistics, 2016
3
The health care workforce in 2016
Home Health and personal care aides ($22k) Nursing aides ($27k) Med asst($32k)
Physicians $220k
Pharm$122k
PT$85k
Registered Nurses ($68k)Lab Tech $51k
Lic PractNurse($44k)
Physician Assistants$101k
Nurse Practitioners$108k
Master’s/Doctoral
Associate’s /Bachelor’s
High School +
Educational level
Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million.Sources: Bureau of Labor Statistics, 2016
4
The base of the pyramid• Some upward mobility
– Nursing assistant RN Nurse Practitioner
• Medical assistants are taking on enhanced roles in patient care
• Home health and other aide jobs tend to be low-skill, minimum-wage, high-turnover with little mobility. From a recent Massachusetts study*:
– Agencies, on average, hired 18 workers over a three month period and lost 15 workers– Home care agencies reported a quarterly home care aide turnover rate of 16%– Nearly 90% of the agencies indicated that recruiting qualified home care aides was their top
workforce challenge– Over 47% of the aides who responded to our survey have at least one other job– 40% live in households with an annual income of less than $20,000– 48.4% were Medicaid recipients
*Home Care Aide Council, “Setting the agenda: Data-driven advocacy to address home care aide policy,” Tufts Health Plan foundation, 2018
5
The center of the pyramid: RNs
6
The RN workforce numbers looked healthy in 2000
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
Total Registered Nurse FTE
Total FTE
Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.
7
But there was a problem…
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
Total Registered Nurse FTE
<35
35-49
50+
Total FTE
Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.
8
The workforce had aged dramatically in 15 years
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
1985 2000
37.9 42.5Year
Average age
20s
30s
40s
50s
60s
9
The newer entry cohorts were smaller at every age
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
25 26 27 28 29 30 31 32Age
FTE by age for two birth cohorts
1954-56 birth cohorts
1964-66 birth cohorts
Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.
10
Nursing schools saw enrollment declines
0
20000
40000
60000
80000
100000
120000
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Total RN degrees awarded
Authors’ analysis of data from the Integrated Postsecondary Education Data System (IPEDS)
11
When we applied a workforce supply model, projected workforce size would peak in 2010 and then decline
Buerhaus, Peter I., Douglas O. Staiger, and David I. Auerbach. "Implications of an aging registered nurse workforce." Jama 283.22 (2000): 2948-2954.
• Shortages would be as high as 500k-1m
12
The shortages did not come to pass
Nursing education programs in 2002 and 2012, by typeCharacteristics 2002 2012 Percentage growth
Public 1,121 (70%) 1,343 (59%) 222 (20%)
Private not-for-profit 456 (28%) 635 (28%) 179 (39%)
Private for-profit 34 (2%) 292 (13%) 258 (759%)
Buerhaus, P., Auerbach, D., Staiger. D. (2014). The rapid growth of graduates from associate, baccalaureate and graduate programs in nursing. Nursing Economic$. 32(6), 290-295, 311.
13
Students taking the NCLEX exam doubled
-
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Number taking the NCLEX exam
Total Domestic,first-timeADN
BSN
Authors’ analysis of data from National Council of State Boards of Nursing
14
As did RN graduates
Auerbach, David I., et al. "The nursing workforce in an era of health care reform." New England Journal of Medicine 368.16 (2013): 1470-1472.
15
Number of RNs (FTE) under age 30
0
100,000
200,000
300,000
400,000
500,000
600,00019
7919
8019
8119
8219
8319
8419
8519
8619
8719
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
1220
1320
1420
1520
1620
17
Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.
16
New RN cohorts (Millennials) have now far surpassed the baby boomer generation
0%20%40%60%80%
100%120%140%160%180%
1920
1923
1926
1929
1932
1935
1938
1941
1944
1947
1950
1953
1956
1959
1962
1965
1968
1971
1974
1977
1980
1983
1986
1989
1992
Likelihood of someone born in a given year to become an RN, relative to 1955 birth year
Authors’ analysis and modeling of workforce data from the Current Population Survey and the American Community Survey
17
And Millennial RNs are projected to far surpass the peak numbers of baby boom RNs
0500,000
1,000,0001,500,0002,000,0002,500,000
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
2019
2021
2023
2025
2027
2029
Number of Registered Nurses Employed on A Full-Time Basis by Generation: Historical and Projected
baby boomers (actual) Gen X (actual) Millenials (actual)baby boomers (forecast) Gen X (forecast) Millenials (forecast)Pre-boomers (actual)
Auerbach, David I., Peter I. Buerhaus, and Douglas O. Staiger. "Millennials Almost Twice As Likely To Be Registered Nurses As Baby Boomers Were." Health Affairs 36.10 (2017)
18
RN hourly earnings have been flat since 1990
$0
$5
$10
$15
$20
$25
$30
$3519
7919
8019
8119
8219
8319
8419
8519
8619
8719
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
1020
1120
1220
1320
1420
1520
16
Authors’ analysis of workforce data from the Current Population Survey
19
What caused the surge?• Stagnant wages, uncertainty in other sectors increased the relative attractiveness of nursing
– Stable, low-risk employment in a career with other psychic benefits
• Public (e.g. Title VIII) and private (e.g. J&J) efforts to boost interest in nursing
• Expanded educational opportunities and pathways
• Forecasts of future shortages?
20
Physicians, NPs and PAs
Home Health and personal care aides ($22k) Nursing aides ($27k) Med asst($32k)
Physicians $220k
Pharm$122k
PT$85k
Registered Nurses ($68k)Lab Tech $51k
Lic PractNurse($44k)
Physician Assistants$101k
Nurse Practitioners$108k
Master’s/Doctoral
Associate’s /Bachelor’s
High School +
Educational level
Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million.Sources: Bureau of Labor Statistics, 2016
21
Physician supply has grown much more slowly than RN supply
0.0
20.0
40.0
60.0
80.0
100.0
120.0
1950 1960 1970 1980 1990 2000 2010 2015
Number of professionals per 10,000 US population
RNs Physicians PAs NPs
22
Physician supply has not kept pace with health spending
1980 2015 % increase
Real health spending per capita $3,354 $9,994 198%
Health care spending as % of GDP 8.9% 17.7% 99%
RNs per capita 54.0 98.5 82%
Physicians per capita 18.6 27.9 50%
Health care spending adjusted by CPI to 2015 dollars
0%50%
100%150%200%
Real health spending percapita
Health care spending as %of GDP
RNs per capita Physicians per capita
% increase, 1980-2015
23
Physician residency slots and applicants
National Residency Match Program, 2017. http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf
24
Higher-paying specialty slots are filled by US students – others are mostly backfilled by international students
(50% of international applicants do not get any slot)
727 total slots
Orthopedic surgery (mean 2016 salary; $535,668)
13 (2%) filled by IMGs
713 (98%) filled by US med students(845 applicants)
1 (<1%) unfilled
Salary data from Doximity as reported in The Atlantic, 2015. https://www.theatlantic.com/health/archive/2015/01/physician-salaries/384846/Residency data from the national residency matching program (NMRP): http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf
Family medicine(mean 2016 salary; $227,541)
2,219 (66%) filled by US med students
3,356 total slots141 (4%) unfilled
996 (30%) filled by IMGs
25
Barriers to entry in the physician market• Residency is required to practice in the US
• The number of positions is jointly determined by hospitals and specialty societies (residency review committees) along with a national accrediting body
– RRCs may limit slots, acting as a guild– Minimum patient volume requirements and hospitals’ financial
interests may also limit slots
Nicholson, Sean. Barriers to entering medical specialties. No. w9649. National Bureau of Economic Research, 2003.
26
States with more physicians have lower physician earnings
$100,000
$120,000
$140,000
$160,000
$180,000
$200,000
$220,000
$240,000
$260,000
$280,000
$300,000
100 150 200 250 300 350 400 450
Aver
age
phys
icia
n ea
rnin
gs
Number of physicians per capita
Active physician per capita from AAMC databook, 2010. Earnings data from American Community Survey pooled data from 2005-2016 excluding physicians earning <$10,000
27
Highest physician fees in low-density areas
Highest physician fees Lowest physician fees
Metro area Relative fee Metro area Relative feeLa Crosse, WI 1.49 Baltimore, MD .73Wausau, WI 1.46 Lowell, MA .74Eau Claire, WI 1.42 Nassau-Suffolk, NY .74Madison, WI 1.41 Washington, DC .75Jonesboro, AR 1.35 Fort Lauderdale, FL .75Janesville-Beloit, WI 1.32 West Palm Beach, FL .75Great Falls, MT 1.29 Miami, FL .76Green Bay, WI 1.28 Providence, RI .76Appleton-Oshkosk, WI 1.27 Dutchess County, NY .77Racine, WI 1.24 San Francisco, CA .77
Government Accountability Office, 2005. “Federal Employees Health Benefits Program: Competition and Other Factors Linked to Wide Variationin Health Care Prices” https://www.gao.gov/assets/250/247411.pdf
28
The adequacy of physician supply• It is debatable how many physicians we need
– Supply may be artificially limited, pushing up wages– But specialists would likely still be highly paid
• Nevertheless, demand for health care will continue to grow faster than physician supply
– CMS projects annual health spending growth >5%/year from 2017-2026, driven by population aging, prescription drugs
– Physician supply is projected to grow <1% per year*• We project that it will actually decline (per capita) in rural areas
AAMC, 2017. The Complexities of Physician Supply and Demand:Projections from 2015 to 2030, 2017 update.
29
Other clinicians will likely fill some of the gap
• Physician assistants (PA), nurse midwives (NM), nurse practitioners (NP) and nurse anesthetists (NA)
– Typically 2-3 years educational requirements beyond baccalaureate degree (more NPs earning doctorates)
– Earnings are roughly half of physicians– Considerable overlap with physician-provided care
• AAMC ‘high’ assumptions for reduction in physician demand: anesthesiology (60%), women’s health (40%), primary care (50%), medical specialties (30%), surgery (20%), and other medical specialties (30%).
– Scope of practice authority is increasing – Education is expanding (282 NP programs in 2000; 424 in 2016)
30
Most added practitioners between 2015 and 2030 will be NPs and PAs
2001
100,000 physicians
100,000 NPs
100,000 PAs
2016 2030 (proj)
Historical data based onAnalysis of survey data from theUS Census Bureau and the NationalSample Survey of RNs. Projections based on workforce supply model.Publication of results is forthcoming.
31
Final thoughts
• The markets for RNs, NPs and PAs appear flexible, more than that for physicians
• Slow-growing supply of physicians and expanded insurance coverage will increase pressure on states to remove scope of practice laws
• Added cost pressures from ACOs, narrow network plans should push health care organizations to use non-physicians to meet demand
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