Chapter 7

The Healthcare Workforce

CHAPTER OBJECTIVES
Catalogue major health care
professions, educational preparation
and levels of credentialing
Understand roles & responsibilities of
professionals in the overall health care
delivery system
Highlight health care workforce
policies, future expectations and
implications of the ACA

Introduction & Health

Professions (1)
One of largest U.S. employers; 16.4
million, 11.4% U.S. workforce
200+ occupations & professions; At
35% of workforce, hospitals are major
employers (Fig. 7-1)
New vocations result from system
changes, ~5.6 M new jobs in next
decade, more than any other industry

Introduction & Health

Professions (2)
Employment growth highest among
health plans, ambulatory clinics,
home health, offices of practitioners
Specialized positions result from
medical advances, but reduce
flexibility & increases costs
Growing acceptance of multi-skilled
professionals, esp. in hospitals
combining roles in related fields.

Credentialing, Regulating Health

Care Professionals (1)
Government regulation necessary to
protect citizens from incompetent,
unethical practitioners. States are
primary regulators; variations from
state-to-state
~50 occupations regulated by:
1. State licensure
2. Certification
3. Registration

Credentialing, Regulating Health

Care Professionals (2)
The downsides of regulation
Restrictions limit health care
organizations use of personnel and
abilities to innovate in patient care
Restrictions influence professional
educational programs to tailor curricula
to testing requirements

States revising credentialing to

provide more flexibility to fastchanging technology

State Licensure (1)

Most restrictive type of regulation; restricts
entry into fields of practice
State laws define practice scope,
education and testing requirements.
Prevents use of professional titles without
meeting predetermined qualifications
Licensure boards: concern for setting
standards, assessing competence for entry
to fields of practice; power to censure,
warn, revoke

State Licensure: Shortcomings

Assesses only qualifications on entry
to field
Does little to assess continuing
competence; only continuing
education courses
Lax discipline; rarely censure or
revoke licenses

State/National
Certification
State or voluntary professional
organizations attest to education and
performance abilities, e.g. national
boards; Commission on Accreditation of
Allied Health Education Programs.
No legal basis to prevent incompetent or
impaired practice; only probation or
revoking certification
Payers or employers insist on certification.

Registration
Begun by various professions as a
means to network for jobs among
employers, general public
Registration requirements range from
listings of individuals to national
registration programs requiring
educational & testing qualifications,
e.g. registered dietitian.

Physicians (1)
137 U.S. Medical Schools
17,364- 2011 graduates
26 Colleges of Osteopathy
4,200 annual graduates
7% of all U.S. physicians (63,000)
MDs, DOs share same privileges
Medical students ~49% female,
~38% minority

Physicians (2)
Post-graduate training
Most states require at least one
year for licensing; professional
standards require a minimum of 3
years of residency training to
practice a specialty
Residency may range up to 8+
years;
Fellowships required for
certification in subspecialty areas

Physicians (3)
Gap of 5,000 1st year residents filled by
graduates of foreign medical schools
6,000 foreign nationals enter U.S. practice per
year
25% of U.S. practicing physicians

~1300 U.S. citizens attend foreign medical

schools & return to U.S. each year
35% of 700,000 practicing U.S. physicians
are primary care: Internal medicine;
Family practice; Pediatrics

Nursing (1)
Early U.S. Nursing
First professional training program:
1861, Philadelphia Womens Hospital
Pre-WWI, 3 domains: public health,
private duty, hospital
Public health elite: TB & infant care
1920: 70% worked private duty, half in
homes and half for private patients in
hospitals; few employed in hospitals

Nursing: Post WWI

Hospital care & training emphasized;
hospital-based schools of nursing
proliferated to provide sources of low-cost
labor; social & public health aspects were
subjugated to image as symbols of
national sacrifice & efficiency, deferential
to physicians
Nursing leaders promoted high-quality
nursing schools, preferably associated
with universities

Nursing: Training & Education-RNs

2 yr. associate degree

2-3 yr. hospital diploma programs
now defunct
4-5 yr. bachelor degree at
university/college
Specialization followed medicine
starting in 1950s: By 1960s, masters
and doctoral level preparation for
teaching, advanced practice fields;
clinical nurse specialists

Nursing: Employment &

Education Trends-RNs
2010 report: 3 M+ RNs; 84.8%
actively employed; increase of 1.5 M
1980-2008; 1/3 of increase due to
importation of foreign-born
graduates
Hospitals are primary employers,
followed by ambulatory care and
Community/public health (Table 7-2)

Nursing: Employment &

Education Trends-RNs
~90% receive basic education in an
institution of higher education (often
ADN) from community colleges
compared with 20% in 1960; graduatedegreed nurses now comprise 13.2% of
all RNs, twice the percent reported in
1988.
> 180 schools offer doctoral programs:
DNP, DNS, DNSc, DSN and PhD.

Nursing: Employment &

Education Trends-RNs
Hospital consolidations, fiscal
pressures created hospital nursing
stressors: sicker patients, higher
nurse-to-patient ratios, supervision of
lesser-skilled staff
Average RN age of 46 years leveled
off in 2008 with recent increases in
new graduates
Innovations of RWJF, sign-on
bonuses, accelerated programs to

Licensed Practical Nurses

Under supervision of RN or MD
One-year training in ~1,100 approved
technical schools, vocational schools,
community colleges, including classroom &
supervised clinical practice
State license exam required
Hospital positions decreasing; other settings,
e.g. nursing homes, residential care increasing.
Overall employment expected increase of 22%
by 2020.

Nurse Practitioners
RNs with advanced education, clinical
experience; origins in 1960s due to MD
shortage
Most have masters degrees; national
certification required; states prescribe
scope of practice: 400 accredited masters
& 100 accredited post masters programs
Specialize: e.g. neonatal, pediatric, school,
adult, family, psychiatric, geriatric,
obstetric, surgical, emergency
Cost effective, highly regarded; growing

Clinical Nurse Specialist

Developed in response to highly
specialized medicine
Focus on highly complex, sickest
patients
200+ masters programs for specialist
preparation

Dentistry (1)
Early practice by barbers, blacksmiths & MDs
First school chartered in 1840 with 2-year
program; by 1884, 28 schools, most privately
owned; by 1900, most states required licensure
1926: Critical Carnegie report reorganized dental
education.
WWII: recruits poor dental health raised public
health awareness; Selective Service eliminated
all dental standards
1940s: Public health dentistry est. by U of
Michigan; dental public health now a recognized
field with American Board of Dental Public Health

Dentistry (2)
1948: National Institute of Dental Research
est. by U.S. Public Health Service, incorporated
into the NIH
By 1980, 100 M Americans had insurance for
routine & specialized services.
64 dental schools, 2010- 4,996 graduates;
confer DDS or DMD; Women: 50% of school
graduates
Minorities ~12% of school enrollees;
recruitment tactics underway in many venues

Dentistry (3)
Specialties (83% of 155,000 are generalists)
1. Dental public health
2. Endodontics
3. Oral & maxillofacial pathology
4. Oral & maxillofacial radiology
5. Oral & maxillofacial surgery
6. Orthodontics & dentofacial orthopedics
7. Pediatric dentistry
8. Periodontics
9. Prosthodontics

Dentistry: Trends
Recognition of Dental Anesthesiology
under review in 2012 by the ADA as
new specialty
Decline of 1200 graduates per yr.
since 1980
Operates as cottage industry
unaffected by managed care, health
reforms; most in solo practice serve
only paying patients; many lowincome are underserved; absent

Pharmacy (1)
Practice dates to ancient times
Colonial U.S.: Hospital pharmacists were
apprentice MDs; separated in 1765
American Pharmaceutical Association founded
1852; now, 85 U.S. colleges of pharmacy
Employment growing: aging population;
increasing involvement in clinical decisions and
physician/nurse/patient counseling
127 accredited schools grant Pharm.D in 6 year
programs; License requires internship & state
exam

Pharmacy (2)
~12,000 graduates/yr.; ~275,000 active;
employment demand will exceed supply through
2020
Board of Pharmaceutical Specialties certifies
specialists in: nuclear, nutritional support,
oncology, pharmacotherapy, psychiatric,
ambulatory care, critical care, pediatric pharmacy
43% work in commercial community practice; 23%
in hospitals; 34% work in government, for
insurers, for long-term care facilities, other
institutions.

Podiatric Medicine
Diagnoses, treats diseases, injuries of lower
leg and foot.
Prescribes drugs, lab tests, performs surgery
9 accredited U.S. schools; 4 yr., postbaccalaureate education; many opt for 3-4
years post-graduate training to achieve
board certification in specialties: primary
care podiatric medicine, diabetic foot wound
care & footwear, limb preservation &
salvage, or podiatric surgery
Licensure required in all states

Chiropractors
Treat the whole body without drugs or surgery;
believe spinal misalignment and nerve irritation
interferes with normal body functions
15 accredited programs, 2 accredited institutions
Applicants require 90 undergraduate credit hours
All states require licensure
52,000 current practitioners; projected increase
to 67,000 by 2020 due to aging population
demand
Achieve comparable results with MDs for back
pain conditions.
Medicare and many private health plans
coverage

Optometry
Doctors of Optometry (ODs) diagnose vision
problems, eye disease, prescribe treatment,
fit eyeglasses, contact lenses
20, 4-year colleges graduate 1,300/year; 1
yr. residencies for specialization, e.g. family
practice, pediatric, geriatric, low-vision,
cornea & contact lens, etc.
Over 34,000 licensed practitioners
State license requires written & clinical
exams

Health Care
Administrators
Organize, direct, coordinate services
in hospitals, clinics, nursing facilities,
physician practices
Bachelor, master and doctoral
programs; certificate, diplomas
70 schools have accredited masters
programs
Most employed in hospitals, clinics,
physician practices

Allied Health Personnel

200+ occupations supplement

work of physicians, dentists, other
health professionals within 80
allied health fields
Four categories

I.

Laboratory technologists &

technicians
II. Therapeutic science practitioners
III. Behavioral scientists
IV. Support services

I. Laboratory Technologists &

Technicians
State licensed; rapid growth & diversity;
National Accrediting Agency for Clinical
Laboratory Sciences accredits 581
programs; 330,000+, > 50% hospital
employed.
Analyze body fluids, tissues, cells,
chemical contents, bacterial growth,
match blood for transfusions
Technologists: bachelor degrees
Technicians: associate degrees

Radiologic Technology
Supervised by physician radiologists; Joint Review
Committee on Education in Radiology accredits
>700 programs
Training 1-4 years: certificates, associate & bachelor
degrees
Obtains, interprets radiographs, fluoroscopic
images, ultrasound images, CT Scans, MRI scans,
PET scans
Nuclear Medicine Technology: 1 year hospital
certificate programs for radiologic technologists,
RNs or allied health graduates; use of radio active
drugs and detection equipment

Nuclear Medicine
Technology
1- year hospital certificate programs for
radiologic technologists, RNs or allied
health graduates meeting federal
standards for use of radioactive drugs and
detection equipment
50% of states require licensure
Professional certification or registration
is voluntary

II. Therapeutic Science

Practitioners
1.
2.
3.
4.

Physical Therapists
Occupational Therapists
Speech Language Pathologists
Physician Assistants

1. Physical Therapists
(PTs)
State license; doctoral degrees the
norm; 211 accredited programs
Numerous specialties
Graduate accredited colleges;
complete internship
Treat injuries, disabilities, improve
function; collaborative role
Employment: Hospitals, rehab
centers, nursing homes, private
practice

2. Occupational Therapists
(OTs)
Various regulation in all states, ranging
from license to registration
Masters degree required; doctoral degrees
offered.
Assist recovery from injuries to recover
living skills, work abilities; plan educational,
vocational, recreational activities
Employment: Hospitals, nursing homes,
community mental health, adult day care
programs, rehabilitation facilities

3. Speech Language
Pathologists
All states regulate; Masters degree in speech
language or audiology required for license in
27 states
253 colleges & universities offer programs
Evaluate, treat patients of all ages with
communicative, swallowing disorders
Employment: Hospitals, long term care
facilities, schools/universities (~50%), clinics
Expanding employment for aged population
and children with communication disorders

4. Physician Assistants
(PAs)
1961: Duke University initiated for
military corpsmen, medics
All states grant treatment privileges
Many specialties; diagnose, give
therapy, counsel, prescribe drugs &
refer under MD supervision
165 programs: many offer masters
degrees, some offer baccalaureate
degrees; a few associate degrees
Rising demand

III. Behavioral Scientists

Social Workers & Rehabilitation
Counselors
Provide social, rehabilitative,
psychological, community
education resources.
Focus on health maintenance,
adjustment to disabilities,
prevention

Social Workers
Bachelors degree required; masters
degree often the employment standard
480 accredited bachelors, 280 masters
programs; 100 doctoral programs prepare
for advanced practice and/or research
Counsel patients, families on personal,
economic, social problems of illness,
disability; arrange community resources
Growing demand in gerontology,
substance abuse, mental health fields

Rehabilitation
Counselors
Bachelors/Masters degree required
for state license or certification
Provide counsel, emotional support,
rehabilitation therapy; test abilities,
skills levels, interests & psychological
state
Develop training plans to maximize
functioning & prepare for
employment.

IV. Support Services: Health

Information Administrators
Bachelors degree in health information
administration is entry-level requirement
Medical record administration in hospitals,
other health facilities; maintain systems
to store & retrieve of patient data for
financial, legal and research purposes
Projected major future increase in
employment; ARRA est. training centers
in variety of related practices to support
EHR implementation

Alternative Therapists (1)

Medical science has fostered publics
interest in alternative approaches
A group of diverse medical and health
care systems, practices and products that
are not presently considered a part of
conventional medicine.
Complimentary Medicine: adds to
mainstream medicine
Alternative: outside the mainstream
NIH Center for Complementary and
Alternative Medicine est. in 1998; ~ 38%
of American use forms of CAM; $ 34 B
expenditures/year

Alternative Therapists (2)

National Center for Complimentary
and Alternative Medicine (NCCAM)

Surveys to estimate extent of use

International study of traditional
medicines
Studies of medicinal herbs
Studies of unusual therapies, e.g.
telepathic healing

Factors that Influence Demand

for Health Personnel (1)
Medical, scientific advances that increase
longevity, chronic care needs and survival
of traumatic events
Physician supply: almost all other
providers depend on physician support
Technologic advances increase specialists
& eliminate other classes of workers, e.g.
laboratory automation
Home care increases with aging
population; reforms shift more care to
community settings; workforce demand

Factors that Influence Demand

for Health Personnel (2)
Corporatization of health care
Hospital consolidations/mergers; vertical
integration into care continuums
Physician practice arrangement
changes: solo->group-> hospital
employment
New provider organizations, e.g. ACOs
Reforms increase users by 25 M+

Healthcare Workforce Issues

& the ACA (1)
Association of Academic Health Centers
defined workforce issues in 1994: central to
health reforms:
Adequacy of supply; geographic distribution;
underrepresented minorities; future quality &
relevance of professional schools programs;
costs of education; competency testing; redefining roles as technology changes; faculty
supply

National Health Care Workforce Commission

Healthcare Workforce Issues

& the ACA (2)
ACA responses to issues with federal support
for:
Loans and scholarships for targeted
professions in underserved areas
Cultural competency training
Minority recruitment
Primary care residency training
FQHC expansions
Community mental health & primary care
integration

The Future: Complexities of National

Health Care Workforce Planning
Until today, no national comprehensive
planning
Stakeholders with different, conflicting priorities
in education, training, regulation, financing etc.
Absence of uniform national & state data
severely confounds future predictions of need
Demographics, consumer demands, new
disease knowledge, delivery & reimbursement
reforms will require workforce role changes &
adaptations