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Health Personnel in the United States • rBg '. . x *o> OwS Health Resources and Services Administration "HRSA—Helping Build AHealthier Nation" The Health Resources and Services Administration has leadership responsibility in theU.S. Public Health Serviceforhealth service and resource issues. HRSApursues its objectives by: Supporting states and communitiesin delivering health care to underserved residents, mothers and children and other groups; Participating in the campaign against AIDS; Servingas a focalpointforfederal organ transplant activities; Providing leadership in improving health professions training; Tracking the supply ofhealth professionals and monitoring their competence through operation ofa nationwide databankon malpractice claims and sanctions; and Monitoring developments affecting health facilities, especially those in rural areas. M+w/;&zfe3 2> Office of Minority Health Resource Center FOBox 37337 ia/ u Washington, DC 20013-733? 1993 r if \fl fl Health Personnel in the United States DHHSPublicationNo.P-OD-94-1 ii •Health Personnel in the United States •NinthReportto Congress •1993 Introduction Legislation enacted in the 1970s requires theperiodic Thehealth care system ofourNation isbeing submission ofreportsbytheSecretary ofthe Department fundementally altered as society struggles to reduce costs ofHealthand HumanServices (DHHS) to theCongress on while maintaining quality and in someareas expanding the status ofhealth personnel supply, distribution, and care. Undoubtedly, anychangeinhow health careis requirements needed to provide adequate health care for delivered to the residentsofthis countrywillalso havean theNation. The currentlegislativebasis for these reports effectonthepersonnel who deliver this care. Thisreport isSection 792(d) ofthe Public HealthServiceActas presents primaryissues affecting the health professions. renumbered by P.L. 102-408, the Health Professions The changing health care system, the major issuefacing Education ExtensionAmendments of 1992. Section 792(d) health personnel, is discussed along with other important was formerlySection 708(d) ofthe Public HealthService and emergingissues such as thedeclining interestin Act, as amended byP.L. 94-484 and furtheramendedby primary carecareers, barriers to practicefor nurse P.L. 95-623, P.L. 100-607and P.L. 100-690. In addition, practitioners, certified nurse midwives, and physician separate legislationmandates reports to Congress on assistants, minority representation and minority health nursing supply, distribution, and requirements (Section concerns, rural health personnel, nurse workforce issues, 951 ofP.L. 94-63asamendedbyP.L. 95-623), and onpublic and thevaryinghealth careneeds ofpersons withAIDS. healthpersonnel (Section 794(c) ofthe Public Health Financingand reimbursementissues have and continueto ServiceActasamendedbyP.L. 94-484and P.L. 95-623 and beexamined and analyzedby the Health Care Financing renumberedSection793(c) oftheActbyP.L. 102-408). This Administration, Prospective Payment Assessment ninthreport, required by the above noted legislation, Commission and the Physician Payment Review presents information on issues affecting health personnel, Commission alongwith others. Therefore, despite the and dataonthe health professions ofmedicine, dentistry, importance ofthese topics to thehealthworkforce, they nursing, physician assistants, allied health, public health, arenot covered in this report. pharmacy, optometry, podiatric medicine, chiropractic, This ninth report also discusses occupation-specific clinicalpsychology, clinical socialwork, and veterinary issues that are affectingorcould affectan occupation's medicine. contribution to thedeliveryofhealthcareto the This currentReportrepresentsanattempt to more population. The reportprovides information on accuratelydepictthe status ofhealthcarepersonnelin the physicians, physician assistants, dentists, nurses, allied United States. Muchofthe data onhealthcarepersonnel health occupations, optometrists, pharmacists, podiatrists, in theUnited States thatappearedinprevious reports can chiropractors, clinical psychologists, clinical social nowbe found ina sisterpublicationentitledFactbook: workers, public health, and veterinary medicine. Health Personnel, United States. This report draws on data from theFactbookand other information toidentifyand discuss some ofthe universallyimportanthealth care issues thatareexpected to affectthedeliveryofhealthcare and the demand forhealth carepersonnel. 2993 •Health Personnel in the United States •NinthReportto Congress • 1 2 •Health Personnel in the United States •Ninth Reportto Congress • 1993 Table of Contents Introduction 1 Individual Disciplines Table ofContents 3 Physicians 53 Executive Summary 5 Physician Assistants 59 Dentists 63 Major Issues Nurses 67 State-level Health Care Reform Initiaitves, Potential Allied Health Introduction 73 Implications for the Health Workforce 13 Dental Hygienists 75 Primary Care Concerns 17 Physical Therapists 77 Analysis ofBarriers to Expansion ofClinical Occupational Therapists 79 Practice forNurse Practitioners and Certified Speech-Language Pathologists Nurse-Midwives 21 and Audiologists 81 Barriers to PhysicianAssistant Practice 27 Respiratory Therapy Personnel 83 Status ofMinority and WomenHealth Care Dietitians 85 Personnel: Availability to Provide Careto Special Populations 33 Diagnostic Imaging and Ionizing Therapy Personnel 87 HealthCare in RuralAmerica 37 Medical Records Personnel 89 Preparing a Nurse WorkforceAppropriate for Currentand Future Health Care Delivery 43 Clinical Laboratory Personnel 91 Health Care Services for Persons Public Health 93 with HIV/AIDS 47 Pharmacists 95 Optometrists 97 Podiatrists 99 : Chiropractors 101 Clinical Psychologists 103 Clinical Social Workers 105 Veterinarians 107 ListofFigures and Tables 108 1993 •HealthPersonnel in the United States •Ninth Reportto Congress •3 4 •Health Personnel in the United States •NinthReportto Congress • 1993 Summary Executive Health Personnel in the United States: Ninth Report to Major Issues Congress, 1993, is submittedby theSecretary ofthe DepartmentofHealthand Human Services (DHHS) in State-level Health Care Reform Initiatives response to directives ofseveral legislative authorities. The ongoing changes in the financing and delivery of This report provides an overview ofprimary issues health care, especiallyattheStatelevel, hasbeen the affecting the health professions, in particularthe evolving productofefforts to provide more comprehensive health care financing and delivery system. Other coverage and reducethe rate that costs are growing. important and emerging issues presented include the Undoubtedly, any change that alters the delivery ofhealth declining interest in primary care careers; restrictive State care alsowillaffectthe personnelneeded to deliver this practicelaws oracts thatcurrentlyprevent nurse care. practitioners, certified nurse midwives, and physician Several elements ofthe changing health care system assistants fromusing theirfullrange ofskills and will havea direct impactonrequirements forhealth capabilities; the underrepresentation ofminorities in personneland require changes inthemix and type of healthprofessions and its impact onminority health; training theyreceive. Amongthese issues are the growth causes ofshortages ofhealth personnel in ruralareas and ofmanaged caresystems which relyheavilyon associated problems ofaffordability and access to health gatekeepers to ensure appropriate care, and increased care; the need for anappropriatelytrained nursing emphasis on preventive and primarycareservicesin order workforce; and the varyinghealth careneeds ofpersons to controlthe long-term costs resulting from inadequate withHIV/AIDS. Also discussedbyprofession, areissues access to care. which affectthe supply, distribution, and adequacyofeach discipline's abilityto provide health care. Information and Primary Care Concerns data are presented on physicians, physician assistants, dentists, nurses, allied health occupations, public health Most agreethataccess to primary care isbeneficial to the overall health ofthepopulation and helps to control personnel, pharmacists, optometrists, podiatrists, costs. Forthis reason, expanding primary and preventive chiropractors, clinical psychologists, clinical social workers, and veterinarians. serviceshasbeena major objective ofthose seeking to improve the existinghealth care system. Primary health Thisreport'sformatis differentthanthat ofearlier care includes a comprehensive range ofpublichealth, editions. Thereportrepresents anattemptto depictthe preventive, diagnostic, therapeutic, and rehabilitative status ofhealth carepersonnelin theUnited Statesby services, the goals ofwhich areto preventpremature identifyingtheissues affectingthem. Muchofthe data on death, disease and disability; preserve functional capacity; healthcarepersonnel thatappeared in previous reports and enhance overall quality oflife. Awidevariety of canbefound ina companion publication entitledFactbook: health care professionals either provideprimary medical Health Personnel, United States. This reportdraws ondata careorcontributeto its provision. Theseinclude fromtheFactbookand other sources to identify and discuss generalist physicians; some physician assistants and importanthealthcareissues thatwill affectthe delivery of nurses, mostnotably nurse practitioners and certified health careand the demand forhealth carepersonnel. nurse midwives; dentists; podiatrists; and to a lesser degreepharmacists and a few allied health professionals. 1993 •HealthPersonnel in the United States •NinthReportto Congress •5 The domination ofoursystemby specialized health Status of Minority and Women Health Care care providers and the dearth ofadequatelytrained Personnel: Availability to Provide Care to primary care personnel have inhibited access to care and Special Populations. helped escalate health care costs. Anymovement toward a While women have historically dominated the majority moremanaged care approachto providing health care will ofnursing and allied health professions, the 1980s and exacerbate the imbalancebetween theneed for generalists 1990s also sawthem contribute significantly to the growth and the demand for these health care professionals as in traditionally male-dominated occupations such as demand forprimary carepersonnel increases. To meet medicine, dentistry, and optometry. The growth rateof future workforce needs, teaching hospitals, ambulatory minoritywomen in health care occupations has alsobeen facilities, health professions schools, public agencies, and substantial, although suchwomen continue to representa other private entities must assure that an appropriate very smallpercentage ofhealthprofessions graduates asa numberand mix ofhealthprofessionals are trained in an whole. Black women, for instance, were solelyresponsible environment conducive to preparing professionals to for increased blackrepresentation in medicine and deliver primary care that is cost-effective, person-oriented, dentistry. The loss ofblackmale professionals in some interdisciplinary, and community-based. fields and theirfailure to match thegains ofblackwomen in others, represents a critical setbackthatneeds tobe Barriers to Practice for Nurse Practitioners, addressed. Similarly, while the growth ofHispanic Certified Nurse-Midwives and Physician women in allopathic and osteopathic medicine, dentistry, Assistants pharmacy, optometry, podiatry, and veterinary medicine Concern over the lack ofprimary care practitioners, has exceeded that ofall women, their stillverysmall coupled with ongoing efforts to increase access to care for numbers limit their availability to treatthe populations theuninsured and improvepreventive services for all, has thatneed themmost. This is ofspecialconcerninthat broughtfocus on theuse ofnurse practitioners (NPs), Hispanics are the fastest growing minority population in certified nurse-midwives (CNMs), and physician assistants the United States. (PAs) as a means ofprovidingprimary care. Currently, the Manyofthenational health goals fortheyear2000 that extentto which these health care professionals can provide targetwomen and children in low-income and minority primary care is governed by a variety ofrestrictiveState groups depend on increasingthe supplyofwomen and regulations and reimbursement policies. Thebarriers to otherminority health careproviders tobridge the practice affecting each profession are similar in manyways language and cultural gap that ofteninhibits access to care. butwith some differences thataffect their practice Whilewomen will continue to increase their environment. Thenetresult, however, is thatthe optimal representationin many ofthe health careprofessions, an use ofthesepractitioners isbeing compromised. States inadequate supplywill serve as a constrainton the regulatetheirrespective scopes ofpractice and in many Nation's efforts to treatthe populations that need them jurisdictions, despite adequate educational preparation, NPs, CNMs and PAs areunableto perform the servicesfor most. The decliningnumbers ofblackmalegraduates in some professions and the continued underrepresentation whichtheyweretrained. The full utilization ofthe skills ofother minorities indicaterenewed efforts areneeded to ofthese practitioners would have a majorpositive effect on increase therecruitment and retention ofthese achieving the goals ofimproving health care delivery. populations. 6 •Health Personnel in the United States •Ninth Reportto Congress • 1993