hsci 678 intro to us healthcare system health services workforce chapter 8 tracey lynn koehlmoos,...
TRANSCRIPT
HSCI 678 Intro to US Healthcare System
Health Services Workforce
Chapter 8
Tracey Lynn Koehlmoos, PhD, MHA
Roemer Model
• Where are we now?
• Resource Production– Workforce and hospitals– Research and technology
• Where have we been?– Organization of Programs– Management– Economic Support
Health Services Workforce
• Largest Industry in the US
• 11.9 million workers and growing!
• MDs: receive 20% of all personal health expenditures, control 75% of health expenditures
• Nurses, 2 million plus, largest group
• Many more allied professionals
Physicians
• Leadership/entry role in health system• Historical autonomy• Challenges
– Doctor as businessman– Reduced fees– Insurers seek cost containment– Utilization review
• But first…
Medical History 101
• US medical profession followed Brits.
• Apprenticeships, no standardized programs
• 1846—AMA founded, licensing & training– More standardization– More science and research
The Flexner Report
• 1910 by Abraham Flexner and AMA
• Visited 131 US and Canadian med schools
• Found wide variation in all aspects
• Recommended only 31 should stay open
• Johns Hopkins, ideal model
• Closed all but 2 Black medical schools
Med School Today
• About 126 schools for MDs• 12 Osteopathy programs• 4 year program• 17,000 new physicians each year• Rigorous standards• Costly (with great variation)• 50% or more Med School revenue from
provision of services
Graduate Medical Education
• GME, 3-7 year residencies for specialty
• Residents receive stipends
• Each GME costs Fed $70K
• Medicare and Medicaid, largest payers of GME
• No centralized controlling authority
• # Residencies > # Medical Graduates
Who fills the remaining slots?
• International Medical Graduates (IMGs)• Formerly known as FMGs1: to provide foreign MDs with training2: Inexpensive labor for teaching hospitals3: Augment supply of US physicians
IMGs will work in places US physicians will not:Inner City Mental HospitalsPrisons
What do they do?
71%
20%
3% 6%
Office
Hospital
Federal
Other
Supply and Demand
• 813,770 Physicians in US (2000)
• 2/3 Specialists
• Inadequate distribution of providers
• Demand, hard to predict
• Supply, easier to control– Number of Medical School Slots– Number of IMGs based on policy
Specialists v. Generalists
• Generalists: FP’s, Internal Medicine
• 2/3 of physicians are specialists/subspec.
• No emphasis on producing more FPs
• No quick fix
• Managed Care emphasizes the Primary Care Provider (Generalist)—but the idea has not caught on in the US
Physician Summary
• No easy way to predict demand
• There may be an oversupply– True in some areas and specialties– Undersupply in other areas and generalists
• Specialist receive higher reimbursement and more prestige than Generalist
• Generalists are the hub of Managed Care-sort of…
Allied Health Providers
• Laboratory Personnel• PT and OT and RT• Radiology Technicians• Dietitians/Nutritionists• Clinical Psychologists• Speech Pathologist and Audiologists• Medical Records administrators• Medical Social Workers
Midlevel Practitioners
• Physician Assistants (PAs) – Post-Vietnam, medical corpsmen– 20-36 months training– Primary care role good for Managed Care– 55% associated with specialist practices
– Issues of professional territorialism– Licensure restriction
Midlevel Practitioners
• Advance Practice Nurses (APNs)
• Nurse Mid-Wives (4,000)
• Nurse Practitioners (58,500)
• No national standard
• Require physician oversight
• No direct reimbursement to APNs
Nurses
• Largest group in the medical workforce• More than 2 million active nurses• 2/3 work in hospitals• Five levels of nurse education
– CNA—on the job, no certificate– LPN—12 month program (state license)– RN—hospital diploma, AA, BA (state license)– APN—Midwife, ARNP– Clinical specialist—MS (also PhD, ND)
Nursing Shortage
• US-wide, expected to worsen
• Aging nurse workforce (43 average age)
• By 2010, 20% below requirements
• Reality of Nursing:– High entry salary, relatively low increase– Work environment complaints– Cultural change in US
Pharmacists and Dentists
• Pharmacists: 200,000+ – 5-6 years of training– Dependent on MDs to write prescriptions– Increase in elderly patients, increase in
internet and mail order prescriptions
• Dentists: 170,000 – No dependence on physicians!– Have successfully treated decay– Must find other areas to concur including MC
Health Service Administrators
• Highly trained business people and managers (60,000)
• Masters prepared (MHA, MBA, MS)
• Flexibility and leadership– Strategic planning and marketing– Stay current on technology and policies– Accounting and financial management– Clinical management and physical plant
Workforce Summary
• Largest segment of the US workforce
• More women becoming physicians, PAs
• Aging of the nursing workforce
• Racial and Ethnic disparities in all areas