Health Resources and Services Administration
Bureau of Health Professions
National Center for Health Workforce Analysis
Spring 2003
U.S. Department of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
National Center for Health Workforce Analysis
bhpr.hrsa.gov/healthworkforce/
| TABLE OF CONTENTS |
|---|
| EXECUTIVE SUMMARY | ||
| The size and characteristics of the future
health workforce are determined by the complex interaction of the health
care operating environment, economic factors, technology, regulatory and
legislative actions, epidemiological factors, the health care education
system and demographics. Efforts over the past several decades to model
the supply of and demand for health workers show there is a lack of consensus
on the relationship between the health workforce and its determinants, the
future values of many of these determinants, and forecasters' assumptions.
The Workforce Analysis Branch of the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), commissioned a report synthesizing the literature on one set of factors that will have a profound impact on the future health workforce-changing demographics-and discussing its implications for the health workforce. In addition, BHPr commissioned the update of two requirements forecasting models: the Physician Aggregate Requirements Model (PARM) and the Nursing Demand Model (NDM). The major findings of the literature and these two demand models are the following. |
||
| Population Aging | ||
|
||
Increasing Racial and Ethnic Diversity |
||
|
|
|
|
||
Geographic Location of the Population |
||
|
||
Forecasting the Impact of Changing Demographics and Other Factors on Physician Requirements |
||
The PARM forecasts requirements for allopathic (MD) and osteopathic (DO)
physicians providing patient care in 19 specialties as well as physicians
in non-patient-care activities. Requirements are demand-based and rely on
current and forecasted patterns of health care use, physician staffing patterns,
and medical insurance prevalence rates. We consider forecasts under five
scenarios (Exhibit ES.1).
|
|
|
|
| Exhibit ES.1 Forecasted Physician Requirements | ||||||||||||||||||||
|
| The PARM also forecasts requirements for three non-physician specialties: physical therapy, podiatry, and optometry. Based on available data and studies, the requirements for all three professions are projected to increase, between 2000 and 2020, at rates equal to or slightly greater than the growth in population. | ||
Forecasting the Impact of Changing Demographics and Other Factors on Nurse Requirements |
||
|
The NDM forecasts demand-based requirements for FTE registered nurses (RNs),
licensed practical nurses (LPNs), nurse aides and home health aides (NAs).
Although the NDM forecasts requirements at the State level, in this report
we present only national-level forecasts (Exhibit ES.2). Under
a baseline scenario, which represents the forecasts most likely to occur
based on changing demographic and projected trends in other determinants
of nurse demand, total requirements for FTE RNs would increase from approximately
2 million in 2000 to 2.8 million in 2020 (a 41 percent increase). Requirements
for FTE LPNs would increase from 618,000 in 2000 to 905,000 in 2020 (a 46
percent increase). There would also be an increase in FTE nurse aide and
home health aide requirements from 1.5 million in 2000 to 2.3 million in
2020 (a 50 percent increase). Demand for nurses and nurse aides will continue to grow in hospitals during the next two decades, but at a slower rate than for the nursing professions as a whole. The exception results from strong growth in demand for RNs in hospital outpatient settings as technological innovations and managed care trends shift patients from inpatient to outpatient care. The fastest growth in demand will occur in nursing facilities and home health. Under a status quo scenario where patterns of per capita health care use and nurse staffing remain constant over time, the requirement for nurses and nurse aids increases at a slower rate than under the baseline scenario. |
|
| Exhibit ES.2 Forecasted FTE Nurse Requirements | ||||||||||||||||||||||
|
||||||||||||||||||||||
| Findings from the PARM and NDM, as well as the literature review, provide important insights on the impact of changing demographics on the health workforce. This report also identifies areas for additional research such as (a) factors changing the per capita use of health care services, (b) the paucity of information on the relationship between race/ethnicity and the supply of health workers, and (c) the need for models that can forecast demand for and supply of health workers at smaller geographic units of aggregation (e.g., at the sub-State level). |
|
||
| The size and characteristics of the future
health workforce are determined by the complex interaction of the health
care operating environment, economic factors, technology, regulatory and
legislative actions, epidemiological factors, the health care education
system and demographics. Efforts over the past several decades to model
the supply of and demand (or "requirements") for health workers
show there is a lack of consensus on the relationship between the health
workforce and its determinants, the future values of many of these determinants,
and forecasters' assumptions.
[1]
See, for example, recent articles by Snyderman, Sheldon and Bischoff (2002),
Weiner (2002), Grumbach (2002) and Reinhardt (2002) commenting on recent
physician workforce projections by Cooper et al. (2002). Prescott (2000)
discusses the lack of consensus as it pertains to modeling the nurse workforce.
Furthermore, past forecasts of impending surpluses and shortages of health professionals often failed to materialize, leading to the general consensus that a much better understanding is needed about the dynamics affecting the supply of and demand for health professionals. The Workforce Analysis Branch of the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), commissioned a report synthesizing the literature on one set of factors that will have a profound impact on the future health workforce-changing demographics. In addition, BHPr commissioned the updating of two requirements forecasting models: the Physician Aggregate Requirements Model (PARM) and the Nursing Demand Model (NDM). This report discusses findings from the literature review of the implications of important demographic trends for the health workforce. In addition, this report presents findings from the NDM and PARM to quantify the impact of changing demographics on demand for allopathic (MD) and osteopathic (DO) physicians, registered nurses (RNs), licensed practical nurses (LPNs), nurse aides and home health aides (NAs), physical therapists, optometrists, and podiatrists. This report also presents forecasts from the PARM and NDM for several scenarios with different assumptions regarding the future health care operating environment, the productivity of doctors and nurses, and other factors. |
||
| Although the demographic trends discussed here have implications for the entire health workforce, the discussion in this report is heavily tilted towards the physician and nursing professions. Reasons for this focus include the dominance of these professions in the health workforce literature, the focus on these professions by government commissions and policy makers, and the availability of the PARM and NDM for forecasting requirements for physicians and nurses. | ||
Demographics are a major determinant of the
size and characteristics of the future health workforce, and demographic
trends can be extrapolated with reasonable accuracy one or two decades into
the future. In addition to the growth in size of the U.S. population in
future decades, three demographic trends have profound implications for
the future health workforce:
|
|
|
| Other demographic trends with implications
for the future supply of and demand for health workers include changes in
fertility patterns, family size and composition, longevity, immigration,
and overall health of the population. These trends are discussed within
the context of the three major trends discussed above.
In both the PARM and NDM, requirements are defined as the number of health professionals demanded based on the level of health care services that society is willing to purchase given population needs and economic considerations. Other authors have used “need” to define requirements, where need is based on the analyst’s assessment of what constitutes an adequate supply of health workers, independent of society's willingness or ability to purchase services. Using the PARM and NDM, we forecast future demand for health care services and the derived demand for 19 physician specialties, nurses, and the other health workers listed previously. We forecast a “status quo” scenario that assumes no change in per capita health care utilization patterns, health worker productivity, and health worker staffing patterns. Under such a scenario, between the years 2000 and 2020, changing demographics would cause an estimated 30 percent increase in inpatient days, a 20 percent increase in outpatient visits, and a 17 percent increase in emergency department visits at general, short-term hospitals. Inpatient days at non-general and long-term hospitals would increase by an estimated 33 percent; the number of nursing facility residents would increase by 40 percent; the number of home health visits would increase by 36 percent; and the number of visits to physicians’ offices would increase by 23 percent. The change in demand for health care services would increase requirements for physicians by approximately 33 percent, although the increase in requirements would vary by medical specialty. For example, requirements for cardiologists would increase by an estimated 52 percent while requirements for pediatricians would increase by an estimated 11 percent. Requirements would increase approximately 28 percent for RNs, 30 percent for LPNs, and 33 percent for nurse aides (including home health aides). |
Although demographics are a dominant determinant of the demand for health workers, other important factors are the characteristics of the future health care system, economic considerations, technological advances, and population needs. A detailed discussion of these trends is outside the scope of this project; however, the extant literature in this area is relatively large. [2] The report: The Impact of the Restructuring of the U.S. Health Care System on the Physician Workforce and Vulnerable Populations (The Lewin Group, 1998), contains a literature review that discusses many of these trends. Using the PARM and NDM, we forecast future requirements for selected health care professions under alternative scenarios regarding the future health care operating environment. The baseline scenario in both the PARM and NDM produce the forecasts that are most likely to occur based on changing demographics and projected trends in the factors listed above (e.g., trends in insurance coverage and economic considerations). The baseline forecasts for physician requirements are slightly lower than under the status quo scenario (28 percent growth between 2000 and 2020 instead of 33 percent growth), and the change in requirements for individual physician specialties is quite different in some cases. Under the NDM’s baseline scenario, requirements for RNs grow faster than under the status quo scenario (41 percent growth between 2000 and 2020 instead of 28 percent growth), reflecting different assumptions about changes in average patient acuity levels and other factors. Under the baseline scenario, total requirements for LPNs, nurse aides, and home health aides rise faster than forecasts under the status quo scenario. |
The remaining sections in this report discuss the implications for the health workforce of the aging population (Section 2), the changing racial and ethnic composition of the population (Section 3), and population geographic location (Section 4). Each of these sections presents information on the demographic trend, discusses the implications of the trend on demand for health care services and derived demand for health workers, and discusses the implications for the supply of health workers. Section 5 describes the recently updated PARM and NDM and presents findings from these models. Section 6 summarizes the main findings of this effort and discusses areas for additional research. |
||
Increased longevity and the
One, because the elderly have both greater and different health care needs than the non-elderly, the rapid growth in size of the elderly population could substantially increase overall demand for health care services and consequently the derived demand for health workers. Occupations and settings that disproportionately serve the elderly will experience the largest growth. If health care consumption patterns and physician productivity remained constant over time, the aging population would increase the demand for physicians per thousand population from 2.8 in 2000 to 3.1 in 2020. Demand for full-time-equivalent (FTE) RNs per thousand population would increase from 7 to 7.5 during this same period. Two, physicians will spend an increasing proportion of their time treating the elderly. Our analysis of multiple health care use databases suggests that in 2000 physicians spent an estimated 32 percent of total patient care hours providing services to the age 65 and older population. If current patterns continue, this percentage could increase to 39 percent by 2020. Three, the health workforce is aging along with the general population. As health professionals in the baby boom generation retire and as the pool of potential entrants to the health workforce (i.e., the population age 18 to 30) declines as a percentage of the total population, there is concern that the future supply of health professionals will be inadequate to meet demand. Four, the expected increase in health care expenditures attributed to the growing elderly population will likely place pressures on the Medicaid and Medicare programs to control health care costs. The ratio of working-to-retired Americans will likely decrease, placing budget pressures on other government programs that compete with funding for Medicaid and Medicare. Economic pressures to curb the growth in health care costs could result in policies to reduce the demand for and supply of health workers. |
|
| 2.1 Population Forecasts | ||
| Census Bureau population projections show
significant shifts in the age distribution (Exhibit 2.1) with the number
of elderly increasing in absolute size and as a proportion of the total
population (Exhibit 2.2). The number of elderly, defined as the "age
65 and over" population, will grow by over 50 percent between 2000
and 2020, and by an estimated 127 percent by 2050. Furthermore, the relative
size of the elderly population is projected to increase from 12.6 percent
of the population in 2000 to an estimated 16.5 percent in 2020. Between
2030 and 2050, one in five Americans will be elderly. The most rapidly growing demographic group among age categories is the "oldest elderly." This group is sometimes defined differently by researchers, but the most common definitions are the population age 75 and over, age 80 and over, and age 85 and over. [3] Two factors that contribute to researchers using different age breaks to define the oldest elderly are (1) differences in use of health care services, and (2) small sample size among the oldest elderly when using survey data. In 2000, there were approximately 16.6 million people age 75 and over, 9.2 million people age 80 and over, and 4.2 million people age 85 and over. By 2020, the number of people in these age groups could reach 22 million, 13 million, and 7 million, respectively. |
|
| Exhibit 2.1. Age Distribution of U.S. Population | ||||||||||||||||||||||||||||||||||||||||||||||
 |
||||||||||||||||||||||||||||||||||||||||||||||
| Exhibit 2.1. Age Distribution of U.S. Population (Text Only) | ||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||
| Source: U. S. Census Bureau middle series population projections (Day, 1996). | ||||||||||||||||||||||||||||||||||||||||||||||
| Exhibit 2.2. Projections of U.S. Elderly Population | ||||||||||||||||||||||||||||||||||||||||||||||
|
| 2.2 Implications of an Aging Population for the Demand for Health workers | ||
| 2.2.1 Increasing Demand for Health Care Services | ||
| The greater medical needs of the elderly,
combined with access to health care services through Medicare and Medicaid,
have resulted in much higher per capita use of health care services for
the elderly compared to the non-elderly. On a per capita basis, the elderly
have more hospital inpatient days, outpatient visits, and emergency department
visits. Relative to the non-elderly, they also have more home health visits
per capita and are more likely to be in a long-term care facility.
To illustrate these points, consider Exhibits 2.3 through 2.8 that contain estimates of per capita health care use by age, sex, and urban or rural location for six health care settings modeled in the NDM. The most profound differences in per capita utilization exist across age groups; however, there are also important differences in per capita utilization by sex and by urban or rural location. Many of the following estimates are for 1996, the base year in the NDM, although more recent data are available for some settings. |
||
|
An analysis of the 1996 Health Cost Utilization Project (HCUP) database
finds that with the exception of the age 0-4 population, the number of
inpatient days in general, short-term hospitals per 1,000 population increases
substantially with age for both men and women, in both rural and urban
areas (Exhibit 2.3). Analyses of other patient-level databases such as
the National Hospital Ambulatory Medical Care Survey (NHAMCS), the National
Home and Hospice Care Survey (NHHCS), and the National Nursing Home Survey
(NNHS) produced estimates of per capita health care utilization in different
settings for the eight age groups used in the NDM, by sex, and by urban
or rural location. These are shown in Exhibits 2.4 through 2.8. |
|
| Exhibit 2.3. Inpatient Days in General, Short-term Hospitals (per 1,000 population) | ||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
| Source: Analysis of the 1996 HCUP database with an adjustment so that rates applied to the population in 1996 equaled total inpatient days reported by the American Hospital Association (AHA). See Dall and Hogan (2002). | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Exhibit 2.4. Outpatient Visits in General, Short-term Hospitals (per 1,000 population) | ||||||||||||||||||||||||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||||||||||||||||||
| Source: Analysis of the 1996 NHAMCS database with an adjustment so that rates applied to the population in 1996 equaled total non-emergency, outpatient visits reported by the AHA. See Dall and Hogan (2002). | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Exhibit 2.5. Emergency Department Visits in General, Short-term Hospitals (per 1,000 population) | |||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||