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

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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.

STUDY METHODOLOGY

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.

STATE SUMMARY

Nebraska is a rural, partly frontier, state with a very small minority population.  The state’s proportion of residents without health insurance is below the national average.  Despite the large portion of the state’s population living in non-metropolitan areas, Nebraska’s overall per capita supply of health professionals, other than physicians and nurse practitioners, is equal to or above national ratios.  In addition, the proportion of the state’s population residing in primary care health professional shortage areas (HPSAs) is less than half the national average, and the percentage living in dental HPSAs appears to be even smaller in comparison to the national proportion. 

A significant proportion of dentists (30%) and pharmacists (27%) plan to retire in the next decade.  Since 1996, Nebraska’s overall count of practicing physicians has fallen nearly 20 percent.  Vacancy rates for pharmacists and nurses are on the rise in hospitals.  Like most states, Nebraska’s recent challenge to address budget shortfalls has forced the state to reduce Medicaid payment rates for many health care providers and institutions. 

Much of Nebraska’s efforts to address documented health workforce shortages have been targeted to the state’s rural areas.   The state’s loan repayment programs cover most major health professions.  Based at the University of Nebraska Medical Center and provided start-up support by the state in 1990, the Rural Health Education Network  provides a variety of outreach education services to rural health professionals in the state.  The Medical Center’s Rural Health Opportunity Program (RHOP) encourages rural residents to pursue health care careers by obtaining early admission into participating University of Nebraska Medical Center colleges upon completion of studies at other small colleges.  Furthermore, the University’s family practice residency program has five rural training track sites.

The shortage of nurses is an emerging issue, in particular for the state’s larger urban hospitals.  As is true elsewhere, Nebraska’s growing shortage of nurses is compounded by the challenge of nursing education in the state to expand capacity to train more nurses.  The aging of faculty in nursing schools is of growing concern. 

There are growing concerns of a pending shortage of dentists in Nebraska.  Fewer dentists entered practice in the state in the 1990s than in the 1980s.  Very few graduates of the state’s private dental school that remain in the state to practice reportedly locate outside Omaha.  Although, the opposite appears true of graduates of Nebraska’s public dental school, there is a lack of certain dental specialties in rural counties of the state.  A 2001 report on the state of Nebraska’s dental workforce found that many rural dentists nearing retirement are unable to sell their practice.  Dental hygienists are in short supply as a large proportion of dentists would like to hire them but are unable to do so.

I.  WORKFORCE SUPPLY AND DEMAND

Arguably, it is most important initially to understand the marketplace for a state’s health care workforce.  How many health professionals are in practice statewide and in medically underserved communities?  What are the demographics of the population served?  How is health care organized and paid for in the state?  This section attempts to answer some of these questions by presenting state-level data collected from various sources.

Table I-a.

Sources:  U.S. Census Bureau, AARP.

Roughly half of Nebraska residents live in metropolitan areas. Only eleven percent of Nebraska residents are minorities.

Table I-b.

Sources: CDC, AARP, GAO.

Less than half of Nebraska adults with incomes less than $15,000 made a dental visit in the preceding year.

Table I-c.

HPSA = Health Professional Shortage Area

Sources: KFF, AARP, BPHC-DSD.

Only five percent of Nebraska residents don’t obtain health care due to cost, and only ten percent and two percent live in primary care and dental HPSAs respectively.

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.

While Nebraska has fewer physicians per 100,000 population than the national average, the state had more physician assistants, nurses, pharmacists, and dentists per 100,000 population than the U.S. as a whole.

Table I-e.

HPSA= Health Professional Shortage Area

Source: BPHC-NHSC.

Nebraska has slightly more National Health Service Corps professionals per 10,000 population than the U.S. as a whole. 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.

Only ten percent of Nebraska residents receive their 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.

*  Numerator data for physicians and nurse practitioners from state Medicaid agencies were unusable: many professionals were apparently double-counted, perhaps due to varying participation in different health plans.

N/A- Data was not available

Sources: State Medicaid programs, Norton and Zuckerman “Trends”, HPTS, AARP.

Only nine percent of Nebraska physicians enrolled in Medicaid receive payments of greater than $10,000 annually. 

II.  HEALTH PROFESSIONS EDUCATION

State efforts to help ensure an adequate supply of health professionals can be understood in part by examining data on the state’s health professions education programs–counts of recent students and graduates, amounts of state resources invested in education, and other factors.  State officials can gauge how well these providers reflect the state’s population by also examining how many students and graduates are state residents or minorities.  Knowing to what extent states are also investing in primary care education and how many medical school graduates remain in-state to complete residencies in family medicine is also important.

Table II-a.

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.

Just over half of newly entering  medical students in Nebraska 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.”

Over forty percent of allopathic residents in Nebraska are from in-state medical schools.  Less than a quarter of residents in the state are international medical graduates. 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 nineteen percent of graduates from in-state medical schools 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.

The number of baccalaureate nursing students rose slightly from 2001 to 2002, while the number of master’s level nursing students declined.

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.

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 Nebraska 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 Nebraska 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 Nebraska’s programs as well as the perceived effectiveness of these programs.

RECRUITMENT/ RETENTION INITIATIVES

Table V-a.

Source: State health officials.

* Data on health professions affected was not available.

Focused admissions and recruitment of students from rural and underserved areas had a high impact on the supply and distribution of health professionals in the state.

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.)

N/A = Data was not available.
N/A* = Data was not applicable.

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.

Nebraska collects supply data from primary and secondary sources for all the major health professions except dental hygienists.

VI. EXEMPLARY WORKFORCE LEGISLATION, PROGRAMS AND STUDIES

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

Legislation and Programs

L-214 (2001)

This act adds advanced practice nurses and physician assistants to those eligible to participate in loan repayment programs. The law also applies the current law regarding repayment of funds for medical students who do not complete their service commitments to dentists.

L-523 (2000)

This act establishes a multistate licensure compact for nurses. The compact allows registered and practical nurses licensed in states participating to have their licenses recognized by Nebraska. Other states participating in the multistate licensure compact are: AR, DE, ID, IN, IO, ME, MD, MS, NE, NJ, NC, ND, SD, TN, TX, UT, WI.

L-1025 (2000)

This act creates the Nebraska Center for Nursing. Established for five years, the Center’s purpose is to address issues of supply and demand for nurses, including recruitment, retention, and the utilization of nurses. 

Health Professions Tracking Center

University of Nebraska Medical Center

The health professions tracking center  maintains a updated database of actively practicing physicians, physician assistants, nurse practitioners, dentists, and pharmacists in the state. The information from the tracking center is used for shortage area monitoring and program impact evaluation.

Rural Health Education Network

University of Nebraska Medical Center, 1989

The Rural Health Education Network is an umbrella for development of the rural outreach education activities for the University of Nebraska Medical Center.  The network began in 1989 when a taskforce was developed at the medical center for the purpose of creating a multidisciplinary model for educating health care professionals to serve in rural areas.

Rural Health Opportunity Program

University of Nebraska Medical Center

This program is designed to address the special needs of rural areas in the state by encouraging residents of rural areas to pursue healthcare careers. Selected students in the program gain early admission into participating University of Nebraska Medical Center colleges after graduating from Chadron State College or Wayne State College.

Dental Work Force Committee

Nebraska Dental Work Force Committee, 2001

This report looks at the dental workforce in the state of Nebraska. It discusses the expected retirement of roughly one-third of Nebraska’s dentists and the low numbers of dental school graduates remaining in the state. The report also examines the geographic distribution of dentist across the state and the difficulty of dentists and communities in underserved areas. Finally the report looks at what’s already being done to alleviate the problems dentists in the state are facing and makes recommendations for the future.

Workforce Shortages Toolkit

Nebraska Hospital Association, 2002

The Nebraska Hospital Association formed and Issue Strategy Group on Workforce Shortage in Nebraska to address the shortage of health care workers in the state. This report looks at the shortage of various health professionals in hospitals.

VII.  POLICY ANALYSIS

• Nebraska Hospital Association
• University of Nebraska Medical Center
• Nebraska Department of Health and Human Services
• Office of Rural Health and Primary Care
• Office of Oral Health
• Center for Nursing

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

Nebraska is a rural, partly frontier, state with a very small minority population.  The state’s proportion of residents without health insurance is below the national average.  Despite the large portion of the state’s population living in non-metropolitan areas, Nebraska’s overall per capita supply of health professionals, other than physicians and nurse practitioners, is equal to or above national ratios.  In addition, the proportion of the state’s population residing in primary care health professional shortage areas (HPSAs) is less than half the national average, and the percentage living in dental HPSAs appears to be even smaller in comparison to the national proportion. 

Unlike many states, Nebraska has done an admirable job to collect and analyze data on the state’s health workforce supply.  Organized in 1995 as part of a collaborative effort with the State Office of Rural Health, the Health Professions Tracking Center at the University of Nebraska Medical Center annually surveys physicians, nurse practitioners, physician assistants, dentists and pharmacists, and periodically updates the state’s HPSAs.  The Center for Nursing in the Department of Health and Human Services is charged with assessing the supply of Nebraska’s nurses.

Results of recent workforce analyses determined that a significant proportion of dentists (30%) and pharmacists (27%) plan to retire in the next decade.  Since 1996, Nebraska’s overall count of practicing physicians has fallen nearly 20 percent.  Vacancy rates for pharmacists and nurses are on the rise in hospitals.

Much of Nebraska’s efforts to address documented health workforce shortages have been targeted to the state’s rural areas.   The state’s loan repayment programs cover most major health professions.  Based at the University of Nebraska Medical Center and provided start-up support by the state in 1990, the Rural Health Education Network  provides a variety of outreach education services to rural health professionals in the state.  The Medical Center’s Rural Health Opportunity Program (RHOP) encourages rural residents to pursue health care careers by obtaining early admission into participating University of Nebraska Medical Center colleges upon completion of studies at other small colleges.  Furthermore, the University’s family practice residency program has five rural training track sites.

Like most states, Nebraska’s recent challenge to address budget shortfalls has forced the state to reduce Medicaid payment rates for many health care providers and institutions.  While there was consideration given to eliminating adult dental coverage under Medicaid in 2003,  reimbursement rates to dentists in recent years have been mandated to increase.   Such increases appear to have helped raise the proportion of dentists enrolled in Medicaid that receive annual payments greater than $10,000 to nearly half. 

The shortage of nurses is an emerging issue, in particular for the state’s larger urban hospitals.  The state hospital association has formed a workforce shortage strategy group to assist member hospitals to do a better job of recruiting and retaining nurses and other health care workers deemed in high demand and short supply.  Many hospitals are developing partnerships with area nurse training programs to subsidize student education and expand training capacity. 

Medicine

According to state officials, many of the state’s efforts begun in the late 1980s to improve physician supply and address maldistribution have made a difference.   However, concerns persist as a recent survey of rural Nebraska physicians finds close to a third of respondents plan to leave their practice within ten years.  Importantly, two-thirds of the respondents attended a rural high school in the state and nearly 80 percent attended one of the state’s two medical schools.  The proportion of state’s urban physicians doing so, however, is much less.

Physician assistants play an important role in delivering primary care in Nebraska.  Longstanding physician assistant training programs and new rules allowing these providers to operate more independently of their supervising physicians have allowed physician assistants in Nebraska to be more accessible to patients, particularly in rural areas of the state.

Nursing

As is true elsewhere, Nebraska’s growing shortage of nurses is compounded by the challenge of nursing education in the state to expand capacity to train more nurses.  The aging of faculty in nursing schools is of growing concern.  There appears to be growing competition for nurses between urban and rural employers.  Larger hospitals in the cities appear to more effective in recruiting nurses by offering higher salaries and large signing bonuses.  The demand for nurse practitioners, largely in urban areas, appears to have softened as supply is exceeding demand.

Created in 2000 by the legislature to help reduce the state’s nursing shortage, the state’s Center for Nursing collects important information on nursing supply and demand trends across Nebraska and acts as a resource for nurse recruitment and retention and issues ideas for expansion of nurse faculty.  The Center is staffed by the Board of Nursing.  A nurse in Nebraska has to practice in order to be licensed.

Dentistry

There are growing concerns of a pending shortage of dentists in Nebraska.  Fewer dentists entered practice in the state in the 1990s than in the 1980s.  Very few graduates of the state’s private dental school that remain in the state to practice reportedly locate outside Omaha.  Although, the opposite appears true of graduates of Nebraska’s public dental school, there is a lack of certain dental specialties in rural counties of the state.  A 2001 report on the state of Nebraska’s dental workforce found that many rural dentists nearing retirement are unable to sell their practice. 

There have been some recent state efforts to counter problem trends:

• In 1999, Nebraska’s Rural Advisory Commission put dentistry on the same level of financial assistance in regards to loan repayment as medicine.  However, the state’s new dental loan repayment program suffers from a lack of interest, as the program requires a local community match and there appears to little local interest in many smaller towns for supporting a dentist, and most recently from a lack of funds, as the budget has been reduced to help address the state’s recent budget shortfalls. 
• About half of the University of Nebraska dental students that participate in RHOP reportedly return to rural areas of the state to practice.
• In recent years, the University of Nebraska dental school has incrementally increased class size within their limited capacity.  However, the larger objective is to improve in-state retention of graduates and not merely increase class size.  At the same time, there have been proposals to eliminate the dental school to reduce public expenditures at the institution.

Dental hygienists are in short supply as a large proportion of dentists would like to hire them but are unable to recruit.  A new hygiene training program was due to open in 2003 in western Nebraska.

Pharmacists

As elsewhere, rural Nebraska is showing signs of growing shortage of pharmacists.  Twenty-four of the state’s 93 counties have no pharmacist and 18 other counties have two or fewer pharmacists.  The two schools of pharmacy in the state appear unable to replace the aging workforce of pharmacists in the state’s rural counties. 

Data Sources