The Policy Agenda to Expand the Health Workforce

(Download as pdf)

SUMMARY

Leaders of major national health professions education and practice organizations recommended ways to increase the capacity of the nation's health workforce during an AAHC sponsored event on public policy and the health workforce. Representing pharmacy, dentistry and dental hygiene, nursing, medicine, allied health, and public health, association leaders and policy experts identified barriers to increasing the capacity as well as avenues for change and improvement in policymaking related to the workforce. The policy agendas highlighted the piecemeal approach to policymaking and the need for strategic national direction. The AAHC is addressing the implications of the health workforce crisis and assessing options to develop and protect the nation's health workforce. This major initiative is funded in part by the Josiah Macy, Jr., Foundation.

CHALLENGES
Faculty shortages
Across the board, health professions are facing faculty shortages that hamper educational capacity. 76 out of 99 schools of pharmacy reported vacant or lost faculty positions in 2004-2005. In nursing, more than 30,000 qualified applicants were turned away from baccalaureate programs in 2005, largely due to faculty shortages.

Distribution
Dentistry in particular noted that maldistribution of providers poses a bigger problem than overall supply shortages. Medicine is also examining problems in distribution.

Funding
All professions described how lack of institutional resources and state and federal funding are constraining expansion of the health workforce.

POLICY ISSUES

• State and federal support is needed for the continuation and expansion of health professions educational programs. Faculty, facilities, and residency programs all require strong sustained funding. Cuts to Titles VII and VIII of the U.S. Public Health Service Act, which includes programs for training, faculty development, and pipeline expansion, must be reversed. Scope of practice laws were highlighted as barriers to increasing access to care.
• Comprehensive data collection, research, planning, and policy advocacy are needed for the health workforce, and must entail collaboration across the health professions.
• Governors must become aware of the health workforce as an economic issue.
• Pharmacy requires strengthened support for residency programs.
• Changes in licensure and regulation of dental hygienists can improve the distribution of access to oral health care.
• Nursing education needs stronger support at the state and local level.
• Expansion of the physician workforce is limited by the number of GME slots.
• New uniform standards are needed for the education, licensure, and practice of allied health professionals in order to ensure quality of care and enable these workers to function most effectively together with other health professionals.

ISSUES FOR ACADEMIC HEALTH CENTERS

• Academic health centers must focus on a triangle of concerns: supply, educational models, and practice models.
• Institutional policies and structures require change to ensure the viability of interdisciplinary education. For team-oriented practice to emerge successfully in health care delivery, health professionals and educational structures will need to change to accommodate this future.
• Health professions schools will need to promote faculty retention and development in order to boost educational capacity.

ISSUES FOR THE AAHC

• The Association of Academic Health Centers can provide comprehensive leadership to oversee new ideas and policies for the development of the health workforce. The AAHC is positioned to issue a report for the 21st century that looks across the professions. just as the Flexner Report of 1910 revamped medical education.

Pharmacy Agenda

Pharmacy Education

• 75 of 99 colleges of pharmacy are not part of an academic health center. This poses a barrier to interdisciplinary education and team training/practice.
• Debate over the sufficiency of a bachelor's degree in pharmacy led to that degree's elimination in 2004. The PharmD, a doctorate, is the new required degree for pharmacists entering the profession.
• Pharmacy's application-to-enrollment rate has been rising, with 7 applicants now for every slot. Thanks to schools' commitment to increase capacity, 33% more people will graduate in the next few years compared with 2000. However, faculty shortages are a problem, with 76 of 99 colleges reporting vacant or lost positions in 2004-05.
• Pharmacy is struggling to engage underrepresented minorities in schools.
• The profession faces a lack of consensus about specialization and the role of specialized residencies. Furthermore, the federal government provides financial support for first-year pharmacy residencies alone, leaving hospitals to fund specialty residencies themselves.
• Pharmacy technicians play a key role in the pharmacy workforce, but standards for their education and training are not yet uniform.

Pharmacy Practice & Workforce

• The Aggregate Demand Index (ADI) has been monitored since 1999, rating each state's pharmacist shortage on a scale of 1-5. No states have a surplus, and 35 have either moderate or high demand.
• Considering trends in health care problems, drug use, evolution of drug therapy, demographics, and other factors, demand is predicted to significantly exceed national supply of pharmacists in 2020. Predicted shortfall is 157,000.

Policy and Practice Issues

• Team-oriented education is impeded by the fact that pharmacy schools are generally not located within academic health sciences centers and access to other professions is difficult.
• As the market demands greater skills of pharmacists, more residencies must be financed. In particular, more community-based pharmacy residency programs are needed.
• The profession needs to prepare more faculty in order to accommodate the rapid and diverse expansion of colleges.
• Pharmacy technicians are playing an important role in pharmacy practice. Automation and other future technologies are also changing the practice and structure of the profession.

Dentistry and Dental Hygiene Agendas

Dental Education

• Dental schools are increasing attention to populations such as the very young, elderly, and disabled, and focusing on culturally competent care in order to better treat underserved groups.
• Dental schools face faculty shortages.
• The American Dental Education Association affirms that dental schools must remain firmly attached to the University.

Dental Hygienist Education

• Dental hygienist programs are rapidly expanding across the country.  With the expansion of community, junior, and technical colleges, new programs are emerging in these sites.
• There is concern that locating dental hygienist programs outside of dental schools may impede dentists and dental hygienists from learning collaborative working relationships.

Dental Policy and Practice Issues

• There has been a continuous decline in the ratio of dentists per 100,000 population.  However, improvements in efficiency are off-setting that ratio, so the total supply of dentists is not deemed to be an issue.
• Distribution is the main challenge for dentistry; 43 million people live in dental Health Profession Shortage Areas.

Dental Hygienist Policy and Practice Issues

• Dental hygiene has been noted as one of the top 10 fastest growing occupations from 2004-2014 according to the Bureau of Labor Statistics.
• Scope of practice acts that limit the independent practice of dental hygienists as well as lack of Medicaid provider status for dental hygienists in all but 12 states were noted as barriers to care for underserved populations. 
• Dental hygienists recognize the need for a uniform national licensure exam.
• The American Dental Hygienists’ Association advocates the creation of an advanced dental hygienist practitioner position with a credentialing program.  This position would be a mid-level practitioner, following the model of the nurse practitioner which was created in 1965.

Nursing Agenda

Nursing Education

• The demand for access to nursing schools is far outstripping the supply, as more than 30,000 qualified applicants were turned away from baccalaureate programs in 2005.
• Faculty shortages are the primary constraint on nursing schools' enrollment capacity. As the nation's nursing faculty is aging and approaching retirement, the problem is worsening.
• Many nurses seek practical clinical experience before starting a faculty career. The American Association of Colleges of Nursing supports the National Academy of Sciences' recommendation to create a “practice doctorate,” which would guide nurses through the pipeline more quickly.
• Lack of resources for nurse clinical training is hindering efforts to build capacity in the workforce.

Policy and Practice Issues

• Governors need to understand the importance of nursing in state budgets because the primary source of funding for the “bricks and mortar” of nursing education is at the state and local level.
• Governors also should become more aware that health care is a major source of employment and economic engine for the state and the nation.
• Nursing graduate education needs more resources.
• Partnerships with The Department of Veterans' Affairs, the military, and other providers should be considered as opportunities to help fund faculty slots.

Medicine Agenda

Medical Education

• Per capita allopathic medical school enrollment has fallen since 1980. At that point, projections of a physician surplus caused medical schools to freeze enrollment. Now, schools are playing catch-up.
• The number of residency slots is constrained by Medicare funding for graduate medical education (GME). Restrictions on GME funding prevent hospitals from creating new residency programs by instituting caps on the number of students per hospital.
• Within the last 25 years, osteopathic medical schools have grown from 14 to 22 colleges. They have more than doubled their number of graduates to roughly 3,000.
• Osteopathic medicine faces the challenge of growing with faculty from a smaller academic base and fewer clinical training sites.

Medical Practice & Workforce

• Factors influencing future physician supply include medical school production, international migration, and the aging of the physician workforce. In addition, factors such as gender and generational differences, lifestyle choices, changing practice patterns, and changing productivity impact “effective” supply.
• The physician workforce must grow in overall supply as well as resolve uneven distribution in the population.
• Primary care has been the core of osteopathic medicine, but student interest has been declining as primary care physicians must cope with growing debt.

Policy and Practice Issues

• On-going research and data must be available in order to address workforce needs effectively.
• The Association of American Medical Colleges has called for a 30% increase in medical school enrollment over the next decade, but GME slots must be increased if the overall supply of physicians is to increase. An increase in graduates without lifting the cap will merely cut the number of international medical graduates currently entering the U.S.
• Health professionals must work in teams, devising the most efficient use of the entire workforce while ensuring quality of care. Interdisciplinary care depends on strong collaboration and communication.
• The health professions must collaborate on data, research, planning, policy advocacy, and increasing diversity.
• There is a need for a new Flexner report, but one that looks across the health professions as a whole, not at physicians alone.

Allied Health Agenda

Allied Health Education, Practice, and Workforce

• Allied health is facing major shortages. Faculty recruitment and retention are particular problems.
• Allied health lacks a coherent definition or uniform classification system and is not “branded.” Educational programs for allied health are sometimes classed with related professional schools (e.g. dental hygienist programs may fall under a dental school) or are lumped together with other allied health occupations.

Policy and Practice Issues

• Congress has considered allied health workforce programs such as recruitment via public service announcements, scholarships, and loan repayments, but such legislation has not progressed.
• Program continuation and expansion requires state support and revived federal funding through Title VII of the Public Health Service Act.
• Allied health professions need career ladders.
• Immigration policy and student visas impact the supply of allied health workers and should be addressed.

Public Health Agenda

Public Health Education, Practice, and Workforce

• The field faces major shortages as many public health professionals are set to retire.
• Schools of public health have been opening across the country. Over 20 universities are considering opening schools of public health.
• Undergraduate programs are burgeoning. A broad array of joint degree programs—in areas such as medicine, nursing, dentistry, pharmacy, business, and law—are enriching the perspectives of many types of professionals.
• While only 20% of current public health professionals have formal public health training, the field is moving towards greater uniformity in educating its workforce. The recently-created Board of Public Health Examiners will give its first exam in 2008 to test public health students' core competencies.
• Organized partnerships between schools of public health and health departments are creating academic-practice collaboration.
• Ultimately, retention will depend on competitive salaries.

Policy and Practice Issues

• Public health faces political difficulties in attracting public funding, because successful prevention does not yield visible results.
• Greater diversity in the workforce is needed to reduce health disparities and better provide for underserved populations.
• The Association of Schools of Public Health and the American Public Health Association called for a federal student scholarship and loan repayment program, as well as increased funding for HRSA (Health Resources and Services Administration) health profession programs through Title VII and Title VIII of the Public Health Service Act

Concluding Thoughts

Richard A. Cooper, MD
Professor, University of Pennsylvania

Leaders in health face a fundamental issue: There aren't enough health workers.

Health professionals have a gap in supply that cannot be filled under the current silo system. Therefore, health professions will have to deal with a future that is unlike the past.

Efforts to address the workforce shortage should not lose focus by turning to important but subsidiary issues such as quality, efficiency, or diversity. Nor should academic health center leaders try to redesign the American health care system in the process.

Academic health centers must focus on a triangle of three areas: worker supply, educational models, and practice models. Academic health centers should also take note of K-12 education because the K-12 pipeline is a key determinant of health workforce supply.

 

Contributors

L. Antionette Bargagliotti, DNSc, RN
President, National League for Nursing

Ann Battrell, RDH, MSDH(c)
Executive Director, American Dental Hygienists' Association

Geraldine “Polly” Bednash, PhD, RN
Executive Director, American Association of Colleges of Nursing

Richard A. Cooper, MD
Professor, University of Pennsylvania

Thomas W. Elwood, DrPH
Executive Director, Association of Schools of Allied Health Professions

Lucinda L. Maine, PhD
Executive Vice President, American Association of Colleges of Pharmacy

Henri R. Manasse, Jr., PhD
Executive Vice President, American Society of Health-System Pharmacists

Edward S. Salsberg, MPA
Director, Center for Workforce Studies
Association of American Medical Colleges

Stephen C. Shannon, DO, MPH
President and CEO, American Association of Colleges of Osteopathic Medicine

Harrison C. Spencer, MD, MPH
President and CEO, Association of Schools of Public Health

Richard G. Weaver, DDS
Acting Director, Center for Educational Policy and Research
American Dental Education Association