HSAD 7301 / PBHL 5123

HEALTH MANPOWER
HEALTH MANPOWER ISSUES
1. SUPPLY OF MANPOWER
2. DISTRIBUTION OF MANPOWER
3. PRIMARY VERSUS SPECIALTY
4. DIVERSITY
5. INTERNATIONAL MEDICAL
GRADUATES
6. COST OF MEDICAL EDUCATION
HEALTH CARE
EMPLOYMENT
EMPLOYMENT IN HEALTH CARE
14 13.6
13
12.212.5
12 11.511.5 11.6
10.9
10 9.1 9.4
7.9
8 7.3
6.8
MILLION 6.3 6.6
5.8 6.1
6
4.2
4

0
1970 1976 1978 1980 1989 1995 1998 2000 2002

Health United States: 2004

 HEALTH CARE EMPLOYMENT AS A PERCENT
OF CIVILIAN EMPLOYMENT

9.9
10 9.2
9.6
8.9 8.8 8.9
8.7 8.7
9
8
8 7.4

7
PERCENT OF 6 5.5

EMPLOYED 5
CIVILIANS 4
3
2
1
0
1970 1980 1990 1995 1997 1998 1999 2000 2001 2002 2003

Health United States: 2004

HEALTH CARE EMPLOYMENT
BY SITE OF SERVICE - 2003

S
TE
SI
ER
TH RS
O TO
AC
9.4

PR E
O
IR AR
C
CH L
A
TI
1

EN
D
SI
RE TH
AL
4.4

HE
E S
M E R
HO IC
TE
FF
EN
5.4
O
T C
IS E
NT R

Health United States: 2004

DE CA
T
EN
5.7
TI
A E
TP IC
O
U FF S
O IE
N IT

6.4
IA IL
IC C
YS FA
E
PH R
CA

12.3
G
IN
RS
NU

13.8
LS
41.5 I TA
SP
HO

5
0
45
40
35
30
25
20
15
10
% OF EMPLOYMENT
 Table 1.14
Health Care Employment Growth Projections, 2000-2010
Over the next decade, health care employment is expected to grow at a rapid rate.

100% General Health Care Fastest Growing* Specific

90% Occupations Health Care Occupations
2000-2010 Employment Growth

80%

70%
62%
60% 57%
53%
50% 47%

40% 33%
30% 25% 26%
19%
20% 15%

10% 3%
0%
To tal Service M anufacturing Health C are Health C are P ersonal & M edical P hysician Home Health R .N.s
Emplo yment Sector Sector P ractitio ners Support Home C are A ssistants A ssistants A ides
Growth & Technical Occupations A ides
Occupatio ns

*Note: Five of the nation’s top 10 fastest growing occupations are in health care.

Source: Dept. of Labor, Bureau of Labor Statistics. Monthly Labor Review. November 2001.
1. SUPPLY OF MANPOWER
 METHODS TO DEFINE ADEQUATE
SUPPLY OF MANPOWER
NEED-BASED APPROACHES:
• PRACTITIONER/POPULATION RATIO
DEMAND (TASK) BASED APPROACHES:
• UTILIZATION OF SERVICES
• HOURS WORKED
• VISIT PER HOUR-EFFICIENCY
• FTE PHYSICIANS
TREND BASED APPROACHES:
• ECONOMIC EXPANSION
• POPUALTION GROWTH
• WORK EFFORT OF PHYSICIANS
• SERVICES BY NON-PHYSICIANS
 HISTORICAL PHYSICIAN
MANPOWER SUPPLY ISSUES
1960’S DEBATE
• SHORTAGE OF PHYSICIANS
• DOUBLE MEDICAL SCHOOL SLOTS

1981 GMENAC REPORT

• OVERSUPPLY OF PHYSICIANS BY 2000
• SHORTAGE OF PRIMARY CARE PHYSICIANS

1990’S COGME REPORT’S

• OVERSUPPLY OF PHYSICIANS (15-30%)
• SHORTAGE OF PRIMARY CARE
• OVERSUPPLY OF SPECIALIST
• MALDISTRIBUTION OF PHYSICIANS
• UNDERREPRESENTED MINORITIES
 HISTORICAL PHYSICIAN
MANPOWER SUPPLY ISSUES
2000’S COOPER, ET AL
• PHYSICIAN/POPULATION RATIO WILL BE FLAT FOR
NEXT 2O YEARS
• PHYSICAN WORK EFFORT WILL DECREASE
(AGE/GENDER)
• INCREASED NP SUBSTITUTION IN PC
• PROJECTED 2010 DEFICIT OF 50,000
• PROJECTED 2020 DEFICIT OF 200,000
• MAJOR SHORTAGE OF SPECIALIST
 US ALLOPATHIC AND OSTEOPATHIC
MEDICAL SCHOOLS

160
140
NUMBER OF SCHOOLS

120
100 ALLOPATHIC
80 OSTEOPATHIC
60 TOTAL
40
20
0
50

70

78

80

95

00
19

19

20
19

19

19

US CENSUS: STATISTICAL ABSTRACT OF THE UNITED STSTES

 GRADUATES OF ALLOPATHIC AND
OSTEOPATIC MEDICAL SCHOOLS

20500
19000
17500
16000
# OF GRADUATES

14500
13000 ALLOPATHIC
11500 OSTEOPATHIC
10000
8500 TOTAL
7000
5500
4000
2500
1000
1980 1985 1990 1995 1996 1999 2000 2001 2002

Health United States: 2004

 TOTAL US DOCTORS OF MEDICINE

900000
TOTAL
800000 ACTIVE
700000 PRIMARY CARE
# OF PHYSICIANS

600000
500000
400000
300000
200000
100000
0
19

19

19

19

19

19

19

19

19

20

20

20
49

60

70

80

90

95

97

98

99

00

01

02

Health United States: 2004 Primary Care equals Generalist, Family Practice, Pediatrics and Internal Medicine
 ARKANSAS LICENSED
PHYSICIANS
5,300
5,224
5,200

5,100 5,057
5,022
5,000
4,949 4,949
4,900 4,860
4,800

4,700

4,600
1997 1998 1999 2000 2001 2002

Arkansas Department of Health

 TOTAL PHYSICIANS AND PHYSICIANS IN
PATIENT CARE
PER 10,000 CIVILIAN POPULATION
30

25

20
TOTAL PHYSICIANS
15 PATIENT CARE-US
PATIENT CARE-AR
10

0
1975 1985 1995 2001

Health United States:2003

 US AND ARKANSAS ACTIVE PHYSICIAN
POPULATION RATIO PER
100,OOO POPULATION
300

253
250
216
200 196 190

150 150 US
139 132
ARKANSAS
100 85

50

0
1970 1983 1990 2001

US CENSUS: STATISTICAL ABSTRACT

2. DISTRIBUTION OF
PHYSICIANS
 US AND ARKANSAS PERSONS TO NON-
FEDERAL PHYSICIANS

1400
PERSONS PER PHYSICIAN

1200

1000

800 US
600 ARKANSAS

400

200

0
19

19

19

19

19

19

19

19

19

19

19

20

20
68

75

80

85

90

98

99

0
3

ARKANSAS STATISTICAL ABSTRACT

 VARIATIONS IN ACTIVE PHYSICIAN POPULATION
RATIO PER 100,0000 POPULATION-2001
450
419
400 375
350
303
300
RATIO

250 253 248 254 244

231
200 202
190
163 168 174 156
150
100
50
0
U

TE

TE

ID
M

LO O R

N
S

AL RS

K
EW

RK

EV
A

IS

IS

A
N

XA
U

LA
SS

RY

HO
SO EE

SI
N
IF

AD PI
IS

AN
S
JE

ES

SS
A

UR
A

A
AN
CH

SA
S
NA

IP
M
N

I
D

S
U

IA

A
EY
SE
TTS

US CENSUS; STATISTICAL ABSTRACT

 Table 2.5
Number of Physicians per 100,000 Persons by State, 1999
Availability of Physicians varies substantially by state.

WA NH ME
VT
MT ND
MN

OR
WI NY MA
ID SD
MI RI
WY CT
PA NJ
IA
NE OH DE
NV IN
IL MD
UT WV
CO VA DC
CA KS MO
KY
NC
TN
OK AR SC
AZ NM
AL GA
MS
TX
LA

FL

AK

Low (179 - 240)

HI
Medium (241 - 290)

High (291 - 811)

National average is 285

Note: Includes non-federal physicians only.

Source: Physician Characteristics and Distribution in the U.S. 2001-2002. American Medical Association. Kaiser Family Foundation
State Health Facts Online.
 Table 2.6
Active Physicians per 100,000 Persons by Location, 1950-1998
Since 1950, urban areas have seen much more rapid growth in physicians than rural areas.

350
308
Physicians per 100,000 Persons

300
268 271
247
250 234 234 *
204 197
200 185
172 175
149 157151 156
150 132 141 140
124 124
113 108 110
99
100 85 84 84 92
72 78 75 77
61 57 62
52
50

0
Rural (no city of Rural (city Rural (city Small Metro Large Metro Active Physicians
10,000); adjacent >10,000; not adj. >10,000; adj. to (<1,000,000) (>1,000,000) per 100,000
and not adj. To to metro area) metro area) Persons (national
metro area) average)

1950 1960 1970 1980 1990 1998

*Projection for 2000.

Note: Includes all active physicians.
Source: AMA data from the Bureau of Health Professions and Health, United States, 1993.
VARIATION IN ARKANSAS PERSONS TO NON-
FEDERAL PHYSICIANS

6000 69
PERSONS PER PHYSICIAN

56

5000

4000

3000 47 85
27 26
04 84
2000 21 20

1000
6 4 4
47 48 41 8
30 9
15
0
ST

SC

JE

PU
CA

LI

LA

DR

AR
A
TT

FF
AT

LA
FA
LH

EW

SH
TT

LA
LE

ER
E

SK
YE
OU

IN

ND
RI

SO

GT
TT

I
N

VE

N
E

O
R

ARKANSAS STATISTICAL ABSTRACT

 PROGRAMS TO IMPROVE
DISTRIBUTION OF PHYSICIANS
• NATIONAL HEALTH SERVICE CORPS
• AREA HEALTH EDUCATION CENTERS
• MIGRANT & COMMUNITY HEALTH
CENTERS PROGRAMS
• INDIAN HEALTH SERVICE
• RURAL HEALTH CLINICS
 SHORTAGE DESIGNATIONS
HEALTH MANPOWER SHORTAGE AREA:
• 30 MINUTE TRAVEL TIME
• POPULATION/PCP = 3,500:1
• HIGH INFANT MORTALITY
• HIGH POVERTY
MEDICALLY UNDERSERVED AREAS:
• % BELOW POVERTY
• INFANT MORTALITY RATE
• PCP/1000 POPULATION
• SCALE 0-100 WITH <62 =UNDERSERVED
3. PRIMARY CARE VERSUS
SPECIALTY CARE
 TOTAL US PHYSICIANS
900000
800000
700000
600000
TOTAL
500000
PRIMARY CARE
400000
300000
200000
100000
49

60

70

75

80

85

90

95

00

02
19

19

19

20

20
19

19

19

19

19

HEALTH: UNITED STATES

 PERCENT OF ACTIVE PHYSICIANS IN
PRIMARY CARE

60 59.1

50.7
50
PERCENT OF ACTIVE
PHYSICIANS

40 37.3
35.2 34.6 34.7
33.5 33.2 32.6 32.7 33 32.9
30

20

10

0
19 19 19 19 19 19 19 19 19 20 20 20
49 60 7 0 80 90 95 97 9 8 99 00 01 0 2

Health United States: 2004 Primary Care = General/Family Practice, General Internal Medicine, Pediatrics
 AVERAGE RECRUITMENT
SALARIES FOR PHYSICIANS
1999 2000

CARDIOLOGIST $206,000 $238,000

RADIOLOGIST $197,000 $225,000

ANESTHESIOLOGIST $212,000 222,000

ORTHOPEDISTS $245,000 $257,000

FAMILY PRACTICE $136,000 $139,000

INTERNIST $139,000 $139,000

PEDIATRICIANS $132,000 $130,000

Merritt, Hawkins and Associates

 4. DIVERSITY - RACIAL,
ETHNIC AND GENDER ISSUES
 PERCENT FIRST YEAR ENROLLMENT OF
FEMALES IN HEALTH PROFESSION SCHOOLS

100 94.5 92.7

89.3
90 87.5

80
70 64.7
% FEMALE

60 71-72
48.4
50 44.4 80-81
38.8 37.9 37.6
40 90-91
28.9
30 25.8 -99-2000
19.8
20 13.7

10 3.1
0
0
MEDICINE NURSING PHARMACY DENTISTRY

Health United States: 2003 Medicine is Allopathic Schools

 PERCENT NON-WHITE ENROLLMENT IN
HEALTH PROFESSION SCHOOLS

45 41.2

40
36.2 ALLOPATHIC
% OF ENROLLMENT

35 31.9
SCHOOLS
30 26.5
OSTEOPATHIC
25
23.9
SCHOOLS
20.3
19.5 19 NURSING
20 16.417.2
15
15 11.4
OPTOMETRY
9.4
10 8.6
5.9
5.7
5.1 PHARMACY
5 2.7

0 0 0

70-71 80-81 90-91 00-01

HEALTH:UNITED STATES
ASIAN ENROLLMENT IN HEALTH
PROFESSION SCHOOLS
30

25

20 MEDICINE
OSTEOPATHIC
15
OPTOMETRY
10 PHARMACY

0
70-71 80-81 90-91 00-01

Health United States: 2003

 5. INTERNATIONAL
MEDICAL GRADUATES
 INTERNATIONAL MEDICAL GRADUATES

• US CITIZENS WHO ATTEND FOREIGN

MEDICAL SCHOOLS

• FOREIGN NATIONALS WHO SEEK

MEDICAL TRAINING (RESIDENCIES
AND FELLOWSHIPS) IN THE UNITED
STATES
PERCENT OF ACTIVE PHYSICIANS WHO ARE
INTERNATIONAL MEDICAL GRADUATES

30
26.8
25 23.6 23.6 23.8 24.2 24
23
22.4 22.8
20.9
% OF ACTIVE PHYSICIANS

19.6
20

15

10

0
1980 1985 1990 1993 1994 1995 1998 1999 2000 2001 2002

HEALTH: UNITED STATES

 NUMBER OF US AND IMG APPLICATIONS FOR
MEDICAL RESIDENCIES

35000

30000
TOTAL
25000 TOTAL US
20000 US PUBLIC
US PRIVATE
15000 CANADIAN
10000 OSTEOPATHIC
INTERNATIONAL
5000

0
2001 2002 2003 2004

American Association of Medical Colleges: Electronic Residency Application Service

 PERCENT OF RESIDENCY APPLICATIONS
FROM INTERNATIONAL MEDICAL
GRADUATES
41
% OF RESIDENCY APPLICANTS

40.6
40.5

40
40

39.5 39.3
39.2

39

38.5
2001 2002 2003 2004

AMERICAN ASSOCIATION OF MEDICAL COLLEGES: ERAS

6. COST OF MEDICAL
EDUCATION
 FINANCING MEDICAL EDUCATION

MEDICARE 1965 - DIRECT MEDICAL EXPENSE

• PAY REASONABLE COST OF MEDICAL
RESIDENCIES
COBRA 1985
• CHANGED PAYMENT METHOD – PORTION OF
BASE YEAR COST/NUMBER OF RESIDENTS
BBA 97
• LIMITS ON NUMBER OF RESIDENCIES
• COUNT USING 3 YEAR ROLLING AVERAGE
• ENTITIES OTHER THAN HOSPITALS
 FINANCING MEDICAL EDUCATION

MMA 2003
• HOSPITAL SPECIFIC CAPITATED PER
RESIDENT COST BASED ON COST IN
FY85
• ADJUSTED BY INFLATION FACTOR
• ADJUSTED BY MEDICARE SHARE OF
TOTAL HOSPITAL INPATIENT DAYS
 FINANCING MEDICAL EDUCATION

INDIRECT MEDICAL EDUCATION:

• MEDICARE PAYS ADJUSTMENT TO
DRG PAYMENTS (ADD ON)
• ADJUSTMENT BASED ON UPDATE
FACTOR (FY05=1.47, FY06=1.42)
• ADJUSTMENT BASED ON RATIO OF
INTERNS AND RESIDENTS TO BEDS
 COST TO MEDICARE
• APPROXIMATELY 7% OF MEDICARE
EXPENDITURES GO TO GRADUATE
MEDICAL EDUCATION
• APPROXIMATELY $7 BILLION IN 2001
ISSUES:
• REDUCE NUMBER OF RESIDENCIES
• MODIFY CRITERIA FOR PAYMENT
• REDUCE ADJUSTMENT FACTOR
NURSING MANPOWER
 RN GRADUATES OF US
NURSING SCHOOLS
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
1980 1985 1990 1995 1996 1999 2000 2001

Health United States: 2003

 ARKANSAS LICENSED
REGISTERED NURSES
41940
42000
41500 41168
41413 41377

41000
40500
40000
39500
39087 39135
39000 38849

38500
38000
37500
37000
1997 1998 1999 2000 2001 2002 2003

Arkansas Department of Health

 NURSING MANPOWER ISSUES
• DECLINING FACULTY TO TEACH IN
NURSING SCHOOLS
• DECLINING ENROLLMENT IN NURSING
SCHOOLS
• LIFESTYLE AND CULTURAL CHANGES
INFLUENCING NURSING
• NON-PATIENT CARE OPPORTUNITIES
FOR RN’S
• INCREASING SALARY AND BENEFITS
OTHER HEATH MANPOWER
 ARKANSAS LICENSED
PHARMACISTS
2500 2477

2450
2404
2400

2350 2335 2330

2293 2280
2300 2269
2250

2200

2150
1997 1998 1999 2000 2001 2002 2003

Arkansas Department of Health: Licensed Manpower

 SUMMARY-MANPOWER
• DEFINING NEEDED SUPPLY OF
HEALTH MANPOWER
• IMPROVING DISTRIBUTION OF
HEALTH MANPOWER
• ADEQUATE SUPPLY OF PRIMARY
CARE PROVIDERS
• SYSTEMS TO PAY FOR TRAINING
HEALTH CARE PROFESSIONALS