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
- 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) registered nurses
per thousand population would increase from 7 to 7.5 during this
same period.
- In 2000,
physicians spent an estimated 32 percent of patient care hours
providing services to the age 65 and older population. If current
consumption patterns continue, this percentage could increase
to 39 percent by 2020.
- The aging
of the health workforce raises concerns that many health professionals
will retire about the same time that demand for their services
is increasing. Furthermore, the declining proportion of the population
age 18 to 30 raises concerns regarding the ability to attract
a sufficient number of new health workers.
- The rise
in health care expenditures associated with the rapid increase
in the elderly population will likely place additional pressures
on the Medicaid and Medicare programs, as well as private insurers,
to control health care costs. Such measures would likely decrease
the demand for and supply of health professionals.
- The aging
population could result in rising average patient acuity, which
could in turn require higher nurse and physician staffing levels.
One countervailing trend is that tomorrow's elderly might have
lower disability rates than today's elderly, controlling for age,
because of improvements in economic resources, education levels,
lifestyle, public health, and medical technology.
Increasing
Racial and Ethnic Diversity
- The literature
suggests that Hispanics and non-whites have different patterns
of health care use compared to non-Hispanic whites. Disparities
in access to care account for part of the difference in utilization.
- Demand for
health care services by minorities is increasing as minorities
grow as a percentage of the population. Between 2000 and 2020,
the percentage of total patient care hours physicians spend with
minority patients will rise from approximately 31 percent to 40
percent.
- Minorities
are underrepresented in the physician and nurse workforce relative
to their proportion of the total population. As minorities constitute
a larger portion of the population entering the workforce, their
representation in the physician and nurse professions will increase.
The U.S. will increasingly rely on minority caregivers.
- Minority
physicians have a greater propensity than do non-minority physicians
to practice in urban communities designated as physician shortage
areas. An increase in minority representation in the physician
workforce could improve access to care for the population in some
underserved areas.
Geographic
Location of the Population
- Geographic
variation in population growth rates and in determinants of health
worker demand and supply highlight the importance of developing
forecasting models that can make State-level and sub-State level
forecasts.
- Although
an increasing proportion of the U.S. population resides in urban
areas, a substantial proportion of the population will continue
to reside in rural areas. Many of these rural areas are currently
designated as physician shortage areas.
- Pockets of
urban areas will continue to have a high concentration of minorities.
Many of these areas are currently designated as physician shortage
areas. Efforts to increase the supply of health professionals
in these areas must deal with economic, cultural and language
considerations.
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).
- Scenario
1, Status Quo, forecasts physician requirements under the assumption
that patterns of health care use, medical insurance coverage,
and physician productivity remain constant over time. Under this
sceScenarionario, total requirements for physicians would increase
from approximately 781,300 in 2000 to 1,038,200 in 2020 (a 33
percent increase).
- Scenario
2, Baseline, is our best estimate of demand for physicians based
on changing demographics and projected trends in the other factors
(e.g., insurance coverage and economic considerations). Under
this scenario, physician requirements would increase to 996,400
in 2020 (a 28 percent increase).
- Scenario
3, Universal Coverage, assumes that the entire U.S. population
has medical insurance. Under this scenario, the uninsured population
is placed into the insured fee-for-service and health maintenance
organization (HMO) settings based on the current proportion of
the insured population in each of those two settings. Under this
scenario, total demand for physicians would have been an estimated
817,600 in 2000, increasing to an estimated 1,092,400 (a 40 percent
increase over the 2000 baseline level).
- Scenario
4 is universal health care coverage with 100 percent of the population
enrolled in a health maintenance organization. Under this scenario,
total requirements would have been an estimated 781,900 in 2000,
increasing to an estimated 1,059,900 in 2020 (a 36 percent increase
over the 2000 baseline level).
- Scenario
5, Non-minority Rates, assumes that minorities have rates of medical
insurance coverage similar to non-Hispanic whites within each
demographic group defined by age and sex. Under this scenario,
demand for physicians would have been an estimated 802,400 in
2000, increasing to an estimated 1,072,000 in 2020 (a 37 percent
increase over the 2000 baseline level).
Exhibit
ES.1 Forecasted Physician Requirements
Scenario |
2000 |
2020 |
1: Status
Quo |
781,282 |
1,038,234 |
2: Baseline
|
781,282 |
996,387 |
3: Universal
Coverage |
817,615 |
1,092,381 |
4: 100
percent HMO |
781,889 |
1,059,907 |
5: Non-minority
Rates |
802,356 |
1,072,048 |
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
|
Baseline Scenario |
Status Quo Scenario |
2000 |
2020 |
2020 |
Registered
nurses |
2,001,198 |
2,822,388 |
2,505,747 |
Licensed
practical nurses |
617,946 |
905,159 |
787,329 |
Nurse
aides and home health aides |
1,545,722 |
2,323,518 |
1,983,582 |
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).
Table
of Contents
Introduction
| Aging of the Population | Changing
Racial and Ethnic Composition of the Population | Geographic
Location of the Population | Modeling
the Impact of Changing Demographics on the Future Demand for Health
Professionals | Summary and Conclusions
| References
|