The Health Care Workforce in Eight States: Education, Practice & Policy > Massachusetts

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On this page: Project Description | Study Methodology | State Summary | Workforce Supply and Demand | Health Professions Education | Physician Practice Location | Licensure and Regulation of Practice | Improving the Practice Environment | Exemplary Workforce Legislation, Programs and Studies | Policy Analysis | Data Sources

PROJECT DESCRIPTION

Historically, both federal and state governments have had a role in developing policy to shape the health care workforce.  The need for government involvement in this area persists as the private market typically fails to distribute the health workforce to medically underserved and uninsured areas, provide adequate information and analysis on the nature of the workforce, improve the racial and ethnic cultural diversity and cultural competence of the workforce, promote adequate dental health of children, and assess the quality of education and practice. 

It is widely agreed that the greatest opportunities for influencing the various environments affecting the health workforce lie within state governments. States are the key actors in shaping these environments, as they are responsible for:

• financing and governing health professions education;
• licensing and regulating health professions practice and private health insurance;
• purchasing services and paying providers under the Medicaid program; and
• designing a variety of subsidy and regulatory programs providing incentives for health professionals to choose certain specialties and practice locations.

Key decision-makers in workforce policy within states and the federal government are eager to learn from each other.  This initiative to compile in-depth assessments of the health workforce in 8 states is an important means of insuring that states and the federal government are able to effectively share information on various state workforce data, issues, influences and policies. 

Products of this study include individual health workforce assessments for each of the eight states and a single assessment that compares various data and influences across the eight states.  In general, each state assessment provides the following:

1. A summary of health workforce data, available resources and a description of the extent the state invests in collecting workforce data.  [Part of this information has been provided by the Bureau of Health Professions];
2. A description of various issues and influences affecting the health workforce, including the state’s legislative and regulatory history and its current programs, financing and policies affecting health professions education, service placement and reimbursement, planning and monitoring, and licensure/regulation;
3. An assessment of the state’s internal capacity and existing strategies for addressing the above workforce issues and influences; and
4. An analysis of the policy implications of the state’s current workforce data, issues, capacity and strategies.

The development of the project’s data assimilation strategy, content and structure was guided by an expert advisory panel.  Members of the advisory panel included both experts in state workforce policy (i.e., workforce planners, researchers and educators) and, more broadly, influential state health policymakers (i.e., state legislative staff, health department officials).  The advisory panel has helped to ensure the workforce assessments have an appropriate content and effective format for dissemination and use by both state policymakers and workforce experts/officials.

1. States with limited as well as substantial involvement in one or more of the following areas: statewide health workforce planning, monitoring, policymaking and research;
2. States with presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
3. States with little involvement in assessing health workforce capacity despite the presence of unique or especially challenging health workforce concerns or issues requiring policy attention;
4. Distribution of states across Department of Health and Human Services regions;
5. States with Bureau of Health Professions (BHPr) - supported centers for health workforce research and distribution studies;
6. States with primarily urban and primarily rural health workforce requirements; and
7. States in attendance at BHPr workforce planning workshops or states that generally have interest in workforce modeling.

Collection of Data

NCSL used various means of collecting information for this study.  Methods exercised included:

1. Phone and mail interviews with state higher education, professions regulation, and recruitment/retention program officials;
2. Custom data tabulations by national professional trade associations and others (i.e., Quality Resource Systems, Inc.; Johns Hopkins University School of Public Health) with access to national data bases;
3. Tabulations of data from the most recent edition of federal and state government databases (e.g., National Health Service Corps field strength);
4. Site visit interviews with various officials in the eight profile states;
5. Personal phone conversations with other various state and federal government officials;
6. Most recently available secondary data sources from printed and online reports, journal articles, etc.; and
7. Comments and guidance from members of the study’s expert advisory panel.

Sources:  U.S. Census Bureau, AARP.

Almost all Massachusetts residents live in metropolitan areas.

Table I-b.

Sources: CDC, AARP, GAO.

Nearly ninety percent of Massachusetts adults reported having a routine physical exam within the past two years.

Table I-c.

HPSA = Health Professional Shortage Area

Sources: KFF, AARP, BPHC-DSD.

Massachusetts has half as many residents living in primary care and dental HPSAs as the U.S. as a whole.

Table I-d.

RN= Registered Nurse, LPN= Licensed Practical Nurse, CNM= Certified Nurse Midwife, NP= Nurse Practitioner

CRNA= Certified Registered Nurse Anesthetist

Source: HRSA-BHPr.

Massachusetts has more physicians, nurses, pharmacists, dentists, and dental hygienists per 100,000 population than the U.S. as a whole.

Table I-e.

HPSA= Health Professional Shortage Area

Source: BPHC-NHSC.

Massachusetts’s National Health Service Corp field strength per 10,000 HPSA population is twice than the national average. Table I-f.

MCOs = Managed Care Organizations    HMOs = Health Maintenance Organizations    OB/GYN = Obstetrician/Gynecologist

* This requirement does not preclude MCOs from including additional professions on their provider panels.

Sources: HPTS, AARP.

Forty-five percent of Massachusetts residents receive health care from an HMO.

Table I-g.

¹ Generally seen as an indicator of significant participation in the Medicaid program.

² Denominator number from HRSA State Health Workforce Profile, December 2000.

II.  HEALTH PROFESSIONS EDUCATION

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAMC, AAMC Institutional Goals Ranking Report, AACOM, Barzansky et al. “Educational Programs”, State higher education coordinating boards.

Approximately one-third of newly entering medical students in Massachusetts are state residents.

Table II-b.

¹ Includes estimated number of osteopathic residencies/residents not accredited by the Accreditation Council for Graduate Medical Education.
² Does not include residents from Canada.
³ Explicit payments for both direct and indirect GME cost.

Sources: AMA, AMA State-level Data, AACOM, State higher education coordinating boards, Henderson “Funding”, Oliver et al. “State Variations.”

About one-fifth of all Massachusetts residents are international medical graduates and the same proportion of allopathic residents are  from in-state medical schools.

Table II-c.

¹ Denominator number is state population from 2000 U.S. Census.

Sources: AAFP, AAFP State Legislation, Kahn et al., Pugno et al. and Schmittling et al. “Entry of U.S. Medical School Graduates”.

Only seven percent of graduates in the state were first year residents in family medicine.

Table II-d.

¹ Annual figure for Associate, Baccalaureate, Masters and Doctoral students/graduates for most recent years available.

² Denominator number is the state population from the 2000 U.S. Census.

Sources: NLN, AACN, State higher education coordinating boards.

Massachusetts nursing school enrollments and graduations declined between 2001 and 2002.

Table II-e.

* Denominator number is state population from 2000 U.S. Census.

Source: AACP.

Table II-f.

¹ Denominator number is state population from 2000 U.S. Census.
²  Data was only available from one of the programs in Massachusetts.

Sources: APAP, APAP Annual Report.

Table II-g.

* Denominator number is state population from 2000 U.S. Census.

Source: ADA.

Table II-h.

* Denominator number is state population from 2000 U.S. Census.

Sources: ADHA, AMA Health Professions.

III.  PHYSICIAN PRACTICE LOCATION

The following tables examine in-state physician practice location from two different vantage points: (1) of all physicians who were trained (went to medical school or received their most recent GME training) in the state between 1975 and 1995, and (2) of all physicians who are now practicing in the state, regardless of where they were trained.  Complied from the American Medical Association’s 1999 Physician Masterfile by Quality Resource Systems, Inc., the data importantly illustrates to what extent physician graduates practice in many of the state’s small towns, using the rural-urban continuum developed by the U.S. Department of Agriculture.

Practice location (URBAN/ RURAL) of physicians who received their medical school training in Massachusetts between 1975 and 1995.

Table III-a.

¹ 1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale. Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to   metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum  Code.

Practice location (URBAN/ RURAL) of physicians who received their most recent GME training in Massachusetts between 1978 and 1998.

Table III-b.

¹  1995 Rural/Urban Continuum Codes for Metro and Nonmetro Counties.  Margaret A. Butler and Calvin L. Beale.  Agriculture and Rural Economy Division, Economic Research Service, U.S. Department of Agriculture.

Codes # 00-03 indicate metropolitan counties:

00: Central counties of metro areas of 1 million or more

01: Fringe counties of metro areas of 1 million or more

02: Counties with metro areas of 250,000 - 1 million

03: Counties in metro areas of less than 250,000

Codes # 04-09 indicate non-metropolitan counties:

04: Urban population of 20,000 or more, adjacent to metro area

05: Urban population of 20,000 or more, not adjacent to metro area

06: Urban population of 2,500-19,999, adjacent to metro area

07: Urban population of 2,500-19,999, not adjacent to metro area

08: Completely rural (no place w population > 2,500), adjacent to metro area

09: Completely rural (no place w population > 2,500), not adjacent to metro area

NA: Not Applicable; no counties in the state are in the R/U Continuum Code.

IV.  LICENSURE AND REGULATION OF PRACTICE

States are responsible for regulating the practice of health professions by licensing each provider, determining the scope of practice of each provider type and developing practice guidelines for each profession.  The tables below illustrate the licensure requirements for each of the health professions covered in this study as well as additional information on recent expansions in scope of practice or other novel regulatory measures taken by the state.

Table IV-a.

Sources: State licensing board, HPTS.

Table IV-b.

Source: State licensing board.

Table IV-c.

Sources: State licensing board, AANA, ACNM, Pearson “Annual Legislative Update”, HPTS.

Table IV-d.

Source: State licensing board.

Table IV-e.

Source: State licensing board.

Table IV-f.

Source: State licensing board, ADHA.

Glossary of Acronyms

CNM: Certified nurse midwife.

CRNA: Certified registered nurse anesthetist.

DEA:  Drug Enforcement Agency.

HPSA: Health Professional Shortage Area

NCLEX: National Council Licensure Examination, administered by the National Council of State Boards of Nursing.

NP: Nurse practitioner.

RDHAP: Registered dental hygienist in alternative practice.

V. IMPROVING THE PRACTICE ENVIRONMENT

States have the challenge of not only helping to create an adequate supply of health professionals in the state, but also ensuring that those health professionals are distributed evenly throughout the state.  Various programs and incentives are used by states to encourage providers to practice in rural and other underserved areas.  The tables in this section describe Massachusetts’s programs as well as the perceived effectiveness of these programs.

Source: State health officials.

Massachusetts state health officials rated focused admissions, support for health professions education in underserved areas, and recruitment/placement programs for health professionals as having a high impact on the  supply of health professionals.

LOAN REPAYMENT/ SCHOLARSHIP PROGRAMS *

Table V-b.

* Includes only state-funded programs which require a service obligation in an underserved area.  (NHSC state loan repayment programs are included since the state provides funding.)

Source: State health officials.

WORKFORCE PLANNING ACTIVITIES*

Table V-c.

* One state health official supplied these responses. Therefore, data may be limited and may not accurately reflect all current workforce-planning activities in the state.

Massachusetts frequently collects and analyzes supply data from both primary and secondary sources for all the major health professions.

VI. EXEMPLARY WORKFORCE LEGISLATION, PROGRAMS AND STUDIES

The following abstracts describe several of Massachusetts’s recent endeavors to understand and describe the status of the state’s current health care workforce.

Legislation and Programs

VII.  POLICY ANALYSIS

• Massachusetts Hospital Association
• Massachusetts Nurses Association
• University of Massachusetts School of Medicine
• Commonwealth Corporation

Evidence of Collaboration:  Moderate (largely associated with workforce data collection, profession training, and profession recruitment and retention)

Massachusetts is a significantly urban, high-income and heavily unionized state that historically has provided a generous array of public and privately funded health care services for its recipients.  The state’s initiation in 1997 of a comprehensive expansion of public health insurance coverage under Medicaid—termed MassHealth—is indicative of Massachusetts’ low percentage of children and non-elderly without health insurance which ranks them among the nation’s lowest in rate of uninsura nce.

However, since 2001 when the state began facing severe fiscal pressure and private insurance coverage started to decline, insurance coverage has continue to drop and the viability of the state’s uncompensated care pool of funds is threatened.  Many of Massachusetts’ widely-touted medical centers and hospitals—particularly in the Boston area—have become financially strapped and have not been able to meet increasing demand for services.  Although in the past year the financial woes of health care providers in the Boston market have somewhat subsided, many hospitals continue to struggle with capacity constraints due in part to shortages of physicians, nurses and other skilled health care personnel.          

Despite these growing concerns with workforce shortages, Massachusetts overall enjoys having a much larger than average per capita supply of physicians, nurses and dentists.  In addition, the proportion of the state’s population living in primary care and dental health professional shortage areas (HPSAs) is much less than the national average.  Surprisingly, the ratio of National Health Service Corps to HPSA population in the state is over twice U.S. figures.

Reductions in state support to higher education have also persisted since 2001.  However, with the exception of nursing, a large majority of the state’s medical, dental and pharmacy schools are privately owned. 

As recent as budget proposals for state fiscal year 2005, government health programs, particularly those administered by the Department of Public Health, are slated to continue receiving major funding reductions.  Although Medicaid provider payments have been reduced for certain health providers, overall cuts to the MassHealth (Medicaid) program in recent years have been more modest.  In 2003, Medicaid appropriations actually increased well above normal.  However, coverage for adult dental care (as well as other optional services under Medicaid) was reduced in 2003.

Medicaid provider participation continues to be a concern, particularly for certain health professionals.  Less than 15 percent of the state’s practicing dentists are enrolled to serve MassHealth recipients, due in large part to very low reimbursement rates.  MassHealth’s payment schedule to pharmacists is also viewed as one of the lowest in the nation, and occurs at time when there are growing perceptions that a serious shortage of pharmacists is developing in the state.  This is despite the fact that the state now has three schools of pharmacy.  All students in these schools are now required to graduate (in a longer period of time) with a doctorate degree—now the standard entry to practice educational requirement in most states.  According to reports, most of these students are now women who often choose to work only part time upon graduation. 

Initial statewide efforts to address health care workforce shortages began in 2000 with the establishment of the Massachusetts Health Care Task Force.  The task force was charged with conducting a comprehensive analysis of the state’s health care industry.  That same year, the Massachusetts Health Policy Forum convened a meeting to address health workforce issues in an effort to better understand the growing problem of shortages.  About the same time, a health workforce data center to collect and analyze supply and demand trends of (largely) nurses was created at Worcester State College.  There appears to be a growing interest in developing other resources for statewide research and analysis on other health professions.  The University of Massachusetts School of Medicine Area Health Education Center program is examining the possibility of establishing a workforce data center that researches physician workforce and other health profession supply and demand issues.  Other groups, including the Massachusetts Hospital Association and the Commonwealth Corporation, have expressed concern about the need for greater attention to understanding and analyzing statewide nursing workforce supply and demand. 

Medicine

Studies by the state medical society suggest that a growing number of working and lifestyle issues related to rising malpractice premiums, managed care, third-party reimbursement, cost-of-living and other concerns have made a growing number of physicians consider leaving the state or not beginning to practice in Massachusetts.

Hoping to counter such beliefs and trends, the state’s only public medical school at the University of Massachusetts (out of four total) enjoys a solid reputation of training a large proportion of medical students interested in practicing primary care in the state.  About two thirds of graduating students enter a primary care residency program.  Although the school only accepts state residents as incoming students, the average proportion of entry-level students who are state residents for the state’s four medical schools altogether is just one-third.   A large number of students apply for participation in the school’s physician loan repayment program in which participants must practice primary care in-state upon completion of their residency.  The University says that about 70 percent of these participants ultimately remain in the state to practice.

Nursing

The state's changing demand for and supply of nurses is slowly becoming better understood.  While data appears to show that Massachusetts does not yet have an overall nursing shortage, a 2002 survey of hospitals in Massachusetts found that hospitals face growing nurse vacancy rates (the worst in nearly 15 years).  As nearly 90 percent of hospitals now have some kind of affiliation with a nursing schools to expand enrollment, there is a consensus that any nursing shortage in Massachusetts, like elsewhere, is associated with an insufficient capacity of nurse training programs (associated with shortages of faculty, space and other resources) to educate more nurses.  Increasing numbers of qualified applicants are being turned away from nursing schools due to this lack of capacity.  Commonwealth Corporation, in collaboration with nurse employers and other organizations, and with support from the U.S. Department of Labor funding to the state’s workforce investment boards, established the Nursing Career Ladder Initiative in 2002 to examine the state’s nursing education capacity and make improvements.

In addition, efforts by the state nurses association and others to improve workplace conditions for nurses remain an important policy priority.  Requiring a government-set minimum nurse staffing ratios in the state’s hospitals is currently being supported by the nursing association.

Dentistry

Although low Medicaid payment rates and other factors historically have contributed to limited oral health care access in the state, Massachusetts does not appear to suffer from an overall shortage of dentists.  The state’s three dental schools and seven hygiene schools prepare large numbers of dentists and hygienists. 

However, there is growing concern with the inability of a large low-income, uninsured and disadvantaged population in Massachusetts to access basic oral health services.  Declining participation by dentists in MassHealth, over forty percent of the state’s population live in communities with no fluoridated water, and other concerns spurred the creation in 1998 of a special legislative commission on oral health to address the issue.  A 2000 report by the Commission offered several recommendations to the state for making improvements, including developing more effective oral health information systems, expanding capacity in both the public and private sector to improve access to oral health screening and treatment services, and providing better statewide preventive services for high-risk populations.

Since the report was issued, considerable attention has been made to addressing these problems.  The Massachusetts Department of Public Health’s Office of Oral Health has compiled a comprehensive data base on statewide oral health provider supply and location of MassHealth dental care eligibles.  In addition, the creation of several public-private partnerships involving the Massachusetts Office of Oral Health, Delta Dental Plans, the state’s dental training programs, and others have helped to create and sustain a number of oral health initiatives designed to improve public access to oral health and involve more private dental health professionals in public health functions.  Many of these initiatives require significant amounts of volunteer time from private dentists.  What is lacking largely are new or expanded government programs (e.g., state loan repayment, state-subsidized public health clinics) that interest and enlist more dental health professionals in public practice more of the time.

Data Sources