The robustness of the healthcare workforce David Auerbach, PhD - PowerPoint PPT Presentation

The robustness of the healthcare workforce David Auerbach, PhD External Adjunct Faculty Member, Montana State University Director of Research, Massachusetts Health Policy Commission With help from: Peter I Buerhaus, PhD and Douglas O Staiger, PhD 1

The health care workforce in 2016 Physician Assistants Nurse Practitioners Educational level $101k $108k Physi sicians ns PT PT Phar arm $220k Master’s/Doctoral $85k $122k Associate’s / Lic ic Pract ct Lab ab Regist stere red Nu Nurse ses s ($68k) Bachelor’s Tec Tech Nurse $51k ($44k) k) Med ed asst Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nu Nursing sing a aides ( s ($27k) High School + ($32k) Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million. 2 Sources: Bureau of Labor Statistics, 2016

The health care workforce in 2016 Physician Assistants Nurse Practitioners Educational level $101k $108k Physi sicians ns PT PT Phar arm $220k Master’s/Doctoral $85k $122k Associate’s / Lic ic Pract ct Lab ab Regist stere red Nu Nurse ses s ($68k) Bachelor’s Tec Tech Nurse $51k ($44k) k) Med ed asst Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nu Nursing sing a aides ( s ($27k) High School + ($32k) Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million. 3 Sources: Bureau of Labor Statistics, 2016

The base of the pyramid • Some upward mobility – Nursing assistant  RN  Nurse Practitioner • Medical assistants are taking on enhanced roles in patient care • Home health and other aide jobs tend to be low-skill, minimum-wage, high-turnover with little mobility. From a recent Massachusetts study*: Agencies, on average, hired 18 workers over a three month period and lost 15 workers – Home care agencies reported a quarterly home care aide turnover rate of 16% – Nearly 90% of the agencies indicated that recruiting qualified home care aides was their top – workforce challenge Over 47% of the aides who responded to our survey have at least one other job – 40% live in households with an annual income of less than $20,000 – 48.4% were Medicaid recipients – 4 *Home Care Aide Council, “Setting the agenda: Data-driven advocacy to address home care aide policy,” Tufts Health Plan foundation, 2018

The center of the pyramid: RNs 5

The RN workforce numbers looked healthy in 2000 Total Registered Nurse FTE 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 Total FTE 800,000 600,000 400,000 200,000 - 6 Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.

But there was a problem… Total Registered Nurse FTE 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 <35 1,000,000 35-49 800,000 50+ 600,000 Total FTE 400,000 200,000 - 7 Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.

The workforce had aged dramatically in 15 years 800,000 700,000 600,000 500,000 400,000 20s 30s 300,000 40s 200,000 50s 100,000 60s - 1985 2000 37.9 42.5 Year ear Average age 8

The newer entry cohorts were smaller at every age FTE by age for two birth cohorts 70,000 60,000 50,000 40,000 1954-56 birth cohorts 30,000 1964-66 birth cohorts 20,000 10,000 - 25 26 27 28 29 30 31 32 Age 9 Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.

Nursing schools saw enrollment declines Total RN degrees awarded 120000 100000 80000 60000 40000 20000 0 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 10 10 Authors’ analysis of data from the Integrated Postsecondary Education Data System (IPEDS)

When we applied a workforce supply model, projected workforce size would peak in 2010 and then decline • Shortages would be as high as 500k-1m 11 11 Buerhaus, Peter I., Douglas O. Staiger, and David I. Auerbach. "Implications of an aging registered nurse workforce." Jama 283.22 (2000): 2948-2954.

The shortages did not come to pass Nur ursing ing ed educat cation p ion program ams in in 2002 and and 2012, , by t y typ ype Char aracteristic ics 2002 002 201 012 Percen entage gro rowth Public 1,121 (70%) 1,343 (59%) 222 (20%) Private not-for-profit 456 (28%) 635 (28%) 179 (39%) Private for-profit 34 (2%) 292 (13%) 258 (759%) Buerhaus, P., Auerbach, D., Staiger. D. (2014). The rapid growth of graduates from associate, baccalaureate and graduate programs in nursing. Nursing Economic$. 32 (6), 290-295, 311. 12 12

Students taking the NCLEX exam doubled Numbe ber taking the NC NCLEX exa xam 180,000 160,000 140,000 Total Domestic, 120,000 first-time ADN 100,000 BSN 80,000 60,000 40,000 20,000 - 13 Authors’ analysis of data from National Council of State Boards of Nursing

As did RN graduates 14 14 Auerbach, David I., et al. "The nursing workforce in an era of health care reform." New England Journal of Medicine 368.16 (2013): 1470-1472.

Number of RNs (FTE) under age 30 600,000 500,000 400,000 300,000 200,000 100,000 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 15 15 Authors’ analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek.

New RN cohorts (Millennials) have now far surpassed the baby boomer generation Likelihood of someone born in a given year to become an RN, relative to 1955 birth year 180% 160% 140% 120% 100% 80% 60% 40% 20% 0% 1920 1923 1926 1929 1932 1935 1938 1941 1944 1947 1950 1953 1956 1959 1962 1965 1968 1971 1974 1977 1980 1983 1986 1989 1992 16 16 Authors’ analysis and modeling of workforce data from the Current Population Survey and the American Community Survey

And Millennial RNs are projected to far surpass the peak numbers of baby boom RNs Numbe mber of of Registered N Nurses E Emplo ployed on on A Full ll-Tim ime Basis b by Generat atio ion: Historica ical a and P d Proje ject cted 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 2021 2023 2025 2027 2029 baby boomers (actual) Gen X (actual) Millenials (actual) baby boomers (forecast) Gen X (forecast) Millenials (forecast) Pre-boomers (actual) 17 Auerbach, David I., Peter I. Buerhaus, and Douglas O. Staiger. "Millennials Almost Twice As Likely To Be Registered Nurses As Baby Boomers Were." Health Affairs 36.10 (2017)

RN hourly earnings have been flat since 1990 $35 $30 $25 $20 $15 $10 $5 $0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 18 Authors’ analysis of workforce data from the Current Population Survey

What caused the surge? • Stagnant wages, uncertainty in other sectors increased the relative attractiveness of nursing – Stable, low-risk employment in a career with other psychic benefits • Public (e.g. Title VIII) and private (e.g. J&J) efforts to boost interest in nursing • Expanded educational opportunities and pathways • Forecasts of future shortages? 19 19

Physicians, NPs and PAs Physician Assistants Nurse Practitioners Educational level $101k $108k Physi sicians ns PT PT Phar arm $220k Master’s/Doctoral $85k $122k Associate’s / Lic ic Pract ct Lab ab Regist stere red Nu Nurse ses s ($68k) Bachelor’s Tec Tech Nurse $51k ($44k) k) Med ed asst Home me H Health an and p pers rsonal c care a aid ides ( ($22k) Nursing Nu sing a aides ( s ($27k) High School + ($32k) Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million. 20 20 Sources: Bureau of Labor Statistics, 2016

Physician supply has grown much more slowly than RN supply Number of professionals per 10,000 US population 120.0 100.0 80.0 60.0 40.0 20.0 0.0 1950 1960 1970 1980 1990 2000 2010 2015 RNs Physicians PAs NPs 21 21

Physician supply has not kept pace with health spending 1980 980 201 015 % i % incre rease se Real he health spe h spending pe per r capita $3, $3,354 354 $9, $9,99 994 198% 98% Health c care re spe spending a as s % % of of GDP GDP 8.9% 8. 9% 17. 7.7% 99% 99% RNs pe Ns per r capi pita 54.0 54. 98.5 98. 82% 82% Physician icians p per capit ita 18.6 18 27. 7.9 50% 50% % increase, 1980-2015 200% 150% 100% 50% 0% Real health spending per Health care spending as % RNs per capita Physicians per capita capita of GDP Health care spending adjusted by CPI to 2015 dollars 22 22

Physician residency slots and applicants 23 23 National Residency Match Program, 2017. http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf