The robustness of the healthcare workforce David Auerbach, PhD - - PowerPoint PPT Presentation

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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

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The health care workforce in 2016

Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nu Nursing sing a aides ( s ($27k) Med ed asst ($32k) Physi sicians ns $220k

Phar arm $122k PT PT $85k

Regist stere red Nu Nurse ses s ($68k)

Lab ab Tec Tech $51k Lic ic Pract ct Nurse ($44k) k)

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

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The health care workforce in 2016

Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nu Nursing sing a aides ( s ($27k) Med ed asst ($32k) Physi sicians ns $220k

Phar arm $122k PT PT $85k

Regist stere red Nu Nurse ses s ($68k)

Lab ab Tec Tech $51k Lic ic Pract ct Nurse ($44k) k)

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

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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

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The center of the pyramid: RNs

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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.

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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.

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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 42.5

Year ear Average age

20s 30s 40s 50s 60s

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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 32 Age

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.

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Nursing schools saw enrollment declines

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)

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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

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The shortages did not come to pass

Nur ursing ing ed educat cation p ion program ams in in 2002 and and 2012, , by t y typ ype

Char aracteristic ics 2002 002 201 012 Percen entage gro rowth 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.

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Students taking the NCLEX exam doubled

• 20,000

40,000 60,000 80,000 100,000 120,000 140,000 160,000 180,000

Numbe ber taking the NC NCLEX exa xam

Total Domestic, first-time ADN BSN

Authors’ analysis of data from National Council of State Boards of Nursing

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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.

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Number of RNs (FTE) under age 30

100,000 200,000 300,000 400,000 500,000 600,000 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.

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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

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And Millennial RNs are projected to far surpass the peak numbers of baby boom RNs

500,000 1,000,000 1,500,000 2,000,000 2,500,000 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

Numbe mber of

• f Registered N

Nurses E Emplo ployed on

• n A Full

ll-Tim ime Basis b by Generat atio ion: Historica ical a and P d Proje ject cted

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)

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RN hourly earnings have been flat since 1990

$0 $5 $10 $15 $20 $25 $30 $35 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Authors’ analysis of workforce data from the Current Population Survey

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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?

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Physicians, NPs and PAs

Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nu Nursing sing a aides ( s ($27k) Med ed asst ($32k) Physi sicians ns $220k

Phar arm $122k PT PT $85k

Regist stere red Nu Nurse ses s ($68k)

Lab ab Tec Tech $51k Lic ic Pract ct Nurse ($44k) k)

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

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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

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Physician supply has not kept pace with health spending

1980 980 201 015 % i % incre rease se Real he health spe h spending pe per r capita $3, $3,354 354 $9, $9,99 994 198% 98% Health c care re spe spending a as s % % of

• f GDP

GDP 8. 8.9% 9% 17. 7.7% 99% 99% RNs pe Ns per r capi pita 54. 54.0 98. 98.5 82% 82% Physician icians p per capit ita 18 18.6 27. 7.9 50% 50%

Health care spending adjusted by CPI to 2015 dollars

0% 50% 100% 150% 200% Real health spending per capita Health care spending as %

• f GDP

RNs per capita Physicians per capita

% increase, 1980-2015

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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

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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 slots

141 (4%) unfilled 996 (30%) filled by IMGs

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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.

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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 Averag age p physic sician ian e earnin ings Numb mber o

• f ph

physicians pe per c capi apita

Active physician per capita from AAMC databook, 2010. Earnings data from American Community Survey pooled data from 2005-2016 excluding physicians earning <$10,000

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Highest physician fees in low-density areas

Highest ph physician fees ees Lowest ph physician fees Metro ar area ea Relat ative fe fee Metro ar area ea Relat ative f fee ee La Crosse, WI 1.49 Baltimore, MD .73 Wausau, WI 1.46 Lowell, MA .74 Eau Claire, WI 1.42 Nassau-Suffolk, NY .74 Madison, WI 1.41 Washington, DC .75 Jonesboro, AR 1.35 Fort Lauderdale, FL .75 Janesville-Beloit, WI 1.32 West Palm Beach, FL .75 Great Falls, MT 1.29 Miami, FL .76 Green Bay, WI 1.28 Providence, RI .76 Appleton-Oshkosk, WI 1.27 Dutchess County, NY .77 Racine, WI 1.24 San Francisco, CA .77

Government Accountability Office, 2005. “Federal Employees Health Benefits Program: Competition and Other Factors Linked to Wide Variation in Health Care Prices” https://www.gao.gov/assets/250/247411.pdf

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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.

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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)

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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 on Analysis of survey data from the US Census Bureau and the National Sample Survey of RNs. Projections based on workforce supply model. Publication of results is forthcoming.

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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