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Innovations in Health Workforce Modeling
Academy Health PresentationJune 5, 2004
Presented byTim Dall
The Lewin Group
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Acknowledgements
Sponsored by the National Center for Health Workforce Analysisspecial thanks to:
Steve Tise: project officer for physician workforce studyMarshall Fritz: project officer for nursing demand study
Bill Spencer: project officer for nursing supply studyMarilyn Biviano: former director of NCHWA
The Lewin Group Paul Hogan, Atul Grover, Elisa Golfinopolous
Altarum Charlie Roehrig, Mary Bannister, Sara Eisenstein, Carolina Fulper
• Disclaimer: No official endorsement of this work by the U.S. DHHS or any of its components is intended or should be inferred.
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Agenda
• Data, assumptions and methods used to create four workforce models– Nursing Supply Model (NSM)– Nursing Demand Model (NDM)– Physician Supply Model (PSM)– Physician Demand Model (PDM)
• Additional research needed to make these models more valuable as policy tools
Nursing Supply Model Overview
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• 50 States plus the District of Columbia
• RNs at three education levels
– Diploma or associates degree
– Baccalaureate degree
– Masters or higher degree
• RN age
• Years 2000 to 2020
NSM Projection Dimensions
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• New graduates from U.S. nursing schools
• Immigration of RNs from outside the U.S.
• Change in educational attainment
• Cross-state migration
• Attrition from the licensed RN population (e.g., due to career changes, retirement, death and disability)
• RN labor force participation rates
NSM Projection Determinants
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Nursing Supply Model OverviewB
egin
nin
g of
th
e Y
ear
En
d of th
e Year
US
Grad
uates
Foreign
Grad
uates
Retirem
ent
Death
/disab
ility
Career ch
ange
Education upgrades Cross-state migration Nurse aging
Nurse Population
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• RN population: the number of licensed RNs
• Active RNs: the number of RNs employed in nursing or seeking employment in nursing
• FTE supply: the number of full-time-equivalent (FTE) RNs employed in nursing
Three Measures of RN Supply Projected
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• Sample Survey of RNs (1992, 1996, 2000)– To estimate base year (2000) RN population by age,
education level and State
– To estimate labor force activity rates by RN age and education level
– To estimate cross-state migration patterns
• Current Population Survey (1999-2001)– To estimate RN retirement and disability rates
• Census Bureau population projections 2000 to 2020– To estimate changes in the size of the female population age
20-44, the traditional candidate pool for RNs
NSM Primary Data Sources
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NSM Limitations
• Parts of the NSM are static– Retirement, education upgrades, and labor force participation
patterns constant across States and over time, but differ by RN age and education level
– Cross-state migration patterns constant over time, but vary by State and RN age and education level
– NSM user can change assumptions regarding key variables
• RN supply projections are independent of – RN demand projections– Projected supply of other health workers (e.g., LPNs)
• Small sample size in some surveys (e.g., RN Survey) reduces reliability of projections for smaller States
Nursing Demand Model Overview
Nurse Demand is defined as the number of full time equivalent (FTE) nurses that society is willing to pay for given population needs, economic considerations, the healthcare operating environment, and other factors.
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• 12 settings (e.g., hospitals, nursing homes, home health, doctors offices, public health)
• 50 States plus the District of Columbia• Years 2000 to 2020• RNs, LPNs, nurse aides, home health aides
NDM Projection Dimensions
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• Demographics and geographic location of population
• Characteristics of the health care system—e.g.,– Shift from hospital inpatient to outpatient services– Percent uninsured– HMO saturation rate
• Economic factors—e.g.,– Nurse wages (e.g., ratio of RN to LPN hourly wages)– Reimbursement rates– Per capita personal income
NDM Projection Determinants
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Nursing Demand Model Overview
Nurse Demand Projections
Health care use projections
Nurse staffing intensity equations
Health care use equations
Per capita health care utilization
Trends in health care market conditions,
economic conditions, patient acuity, etc.
Population projections
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• Nurse demand (data for 1996 to 2000)– Sample Survey of RNs: estimates of RNs by employment setting– American Health Care Association: estimates of FTE RNs
employed in nursing facilities• Health care demand (data for 1996 to 2000)
– Area Resource File– National Inpatient Sample– National Ambulatory Care Survey– National Hospital Ambulatory Care Survey– National Nursing Home Survey – National Home and Hospice Care Survey
• Population projections: Census Bureau (data for 1996 to 2020)
NDM Primary Data Sources for RNs
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NDM Limitations
• Simplified model of a complex health care system– Contains limited number of demand determinants– Has limited ability to model effect of economic
determinants on substitution of nurse types– Technology is static
• State-level data used to estimate relationships that occur at the local level
• Small sample size in some surveys (e.g., RN Survey) reduces reliability of projections for smaller States and settings that employ fewer nurses
Physician Supply Model Overview
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• National projections through 2020
• For 36 medical specialties
• Activity Distribution (e.g., patient care, administrative, research, teaching, other)
• Physician age and sex
• IMGs, USMGs, CMGs
• MDs and DOs
PSM Projection Dimensions
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• Current age, sex, USMG/IMG/CMG, and specialty distribution of physician workforce (starting with 2000)
• Annual number of US and international medical graduates
• Recent patterns of specialty choice and activity distribution
• Physician retirement patterns• Physician productivity (especially average hours
worked)
PSM Projection Determinants
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Physician Supply Model Overview
STOCK GROWTH
TOTAL SUPPLY: Specialty, Activity, Age, Sex, Edu.t+1
BASELINE PHYSICIAN SUPPLY
t+1
ACTIVITY DISTRIBUTION
Losses
NEW PHYSICIAN SUPPLY t+1
BASELINE PHYSICIAN SUPPLY:• Specialty Distribution• Activity Distribution• Age• Sex• IMGs, USMGs, CMGs• MD’s and DO’s
Losses
MEDICAL SCHOOL GRADUATES:
• Age
• Sex
• PGY
• IMGs, USMGs, CMGs
• MDs and DOs
SPECIALTY DISTRIBUTION
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• American Medical Association Masterfile– To estimate demographics and specialty distribution of current
MD workforce– To estimate physician activity distribution– To estimate physician retirement rates by age, sex, USMG/IMG– To estimate specialty distribution of new physicians by sex,
USMG/IMG• American Osteopathic Association Masterfile
– To estimate demographics and specialty distribution of current DO workforce
• AMA Socioeconomic Monitoring Survey– To estimate variation in hours worked by physician age, sex,
specialty
PSM Primary Data Sources
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PSM Limitations
• Parts of the PSM are static– Retirement patterns vary by physician age,
sex and USMG/IMG but are constant over time
• Rates reflect long-term historical patterns• Rates do not change with economic conditions
– Specialty choice reflects recent historical patterns, but does not reflect projected demand
Physician Demand Model (PDM) Overview
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• National projections through 2020
• For 18 medical specialties
• For specific population groups defined by age, sex, metropolitan/non-metro location
PDM Projection Dimensions
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• Population projections by age, sex, metro/non-metro location
• Projected insurance distribution• Detailed physician-to-population ratios• Physician/NPC substitution ratios (not used in baseline
projections)• Adjustments to demand projections made outside the
model– Economic growth– Changes in patterns of care
PDM Projection Determinants
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Physician Demand Model Overview
PRACTITIONERREQUIREMENTS
ESTIMATESAssigns 18
specialties and 12 NPC disciplines to
each sex, age, metro/nonmetro and insurance category
POPULATION PROJECTIONS
--Sex, age --Metro/nonmetro --Insurance
PRACTIONER STAFFING RATIOS
--Physicians (18 specialties) --NPCs (12 disciplines)
TRENDS --Sex, age --Metro/nonmetro --Insurance
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• Census Bureau population projections• Estimate utilization of physician services by
patient characteristics, insurance status and delivery setting using:– National Ambulatory Medical Care Survey– National Hospital Ambulatory Medical Care
Survey– National Inpatient Sample– National Nursing Home Survey– National Home and Health Survey
PDM Primary Data Sources
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PDM Limitations
• Demand in base year (2000) is defined by current utilization and service delivery patterns– Assumes physician supply and demand in
equilibrium in base year– Inefficiencies in current utilization and service
delivery patterns extrapolated into the future
• Physician requirements do not reflect overlapping scope of practice (i.e., substitution) between medical specialties
Additional Research Needed
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Additional Research Needed: NSM
• Estimate relationship between number of new RN graduates and– Wages– Working conditions– Teaching capacity– Training costs
• Estimate relationship between RN activity status and – Wages– Working conditions
• RN cross-state migration patterns• Add LPN component
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Additional Research Needed: NDM
• Model demand by skill/training• Estimate employers’ propensity to
substitute between RNs, LPNs and nurse aides based on changes in economic factors (e.g., wages)
• Impact of changing technology on nurse staffing patterns
• Identify additional determinants of demand for nurses and quantify their impact
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Additional Research Needed: PSM
• Physician retirement patterns– AMA data may underestimate retirement– Physician Worklife Survey (conducted by
Sheps Center, UNC) finds higher retirement rates than suggested by AMA data
• Physician specialty choice– How do projected shortages/surpluses for
particular specialties affect specialty choice for new physicians
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Additional Research Needed: PDM
• Alternative estimates of base year demand that do not necessarily assume equilibrium in the base year
• Impact of a growing supply of non-physician clinicians on demand for physician services
• Effect of economic growth on demand for physician services—and the implications for government policies/programs
