Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University, which is establishing a new Center for Health Workforce Research and Policy.
In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.
It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.
For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.
What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.
The Health Workforce: Implications for Access, Costs and Quality
If we are to assure access to care, then we must have an adequate national supply distributed in a manner responsive to need. In many professions, if you just considered the average national use patterns, it would seem that the national supply should be more than adequate, but because of how the supply is distributed and how services are used, there are often many areas of the nation where people cannot adequately access the services. In fact, mal-distribution may be a more significant problem and challenge for the nation than an inadequate total supply.
How we use workers also directly impacts costs, efficiency and quality. For example, if we only allow highly educated practitioners to provide certain services that a person with less education can do just as well, we are likely to drive up costs and may limit access. On the other hand, if we allow a lesser educated caregiver to provide services, it may be beyond their skills and training and we may endanger the health of patients. So how do we know who is qualified to provide what services? The answer is usually determined by a combination of the professional self-regulation and state licensure/scope of practice laws and regulations.
Unfortunately, the nation has invested very little for research on the relationship between the workforce and outcomes. State legislators are regularly caught in the middle between competing professions, with one profession arguing to be permitted to do more to improve access and save money, and the other arguing that lives will be lost. We invest billions in determining the effectiveness of pharmaceutical interventions and almost nothing to assess the impact of the workforce on outcomes!
Other Important Aspects of the Health Workforce
- The diversity of the workforce. The health workforce in totality is diverse in terms of race and ethnicity. Unfortunately, it is very stratified by the level of education required for entry into the profession, with Blacks-African Americans and Hispanics-Latinos very under-represented in the more highly educated (and compensated) health professions, but over-represented in some lower entry level (and lower paying) occupations. This imbalance has impacts on outcomes and has equity implications as well.
- Health care as a jobs generator. Even through the recession, health care jobs grew — in fact, they grew at a healthy rate. This includes jobs in specific health occupations, as well as non-health care jobs, such as accountants and food service workers, in hospitals and elsewhere in the health sector. But with recent sharp increases in enrollment in many health profession schools and a possible future slowing of job growth in more labor intensive settings like hospitals, it is not clear if health care will be the job generator in the future that it has been in the past.
- The role of the federal government. Key decisions impacting on the education, training, distribution and use of health workers do not rest with the federal government. States, professional associations, schools, health systems, and others play more central roles. But the federal government is expected to help assure that all Americans have access to high quality care and that costs are constrained. With this limited role, what can the federal government do to better assure an adequate supply and distribution of well-prepared health workers?
- The global health workforce. In 2010, the US signed the WHO Global Code of Practice on the International Recruitment of Health Personnel. That agreement committed the US to globally responsible health workforce policies, including doing a better job of meeting our workforce needs and reducing our reliance on foreign-educated health workers from less-developed countries, as well as providing assistance to other countries. There is growing awareness of the global aspects of health and the health workforce.
- Health workforce projections. Assuring an adequate supply and distribution of health practitioners requires a projection of future supply, demand, need and distribution. Educational institutions and individuals need to know where the job opportunities will be in the future. But making good projections is extremely challenging, as there are many unknowns on both the supply and demand side. Furthermore, national projections may tell us very little about the likely adequacy of the supply in individual states and communities. Bottom line: good projections are very important but very difficult.
A word about this series. Over the years I have worked with states, professional associations, educational institutions, foundations, and others to advance the science around health workforce data and information to inform public and private decision making. This Health Affairs Blog series will try to bring analysis, data, and evidence to the health workforce discussion — hopefully, it will be interesting and provocative as well. In the end, the goal is to promote research and policies to assure a supply and distribution adequate to provide quality, efficient care for all Americans.