Table Of ContentHealth Personnel in the United States
• rBg
'.
.
x
*o>
OwS
Health Resources and Services Administration
"HRSA—Helping Build AHealthier Nation"
The Health Resources and Services
Administration has leadership responsibility in
theU.S. Public Health Serviceforhealth service
and resource issues. HRSApursues its
objectives by:
Supporting states and communitiesin
delivering health care to underserved
residents, mothers and children and other
groups;
Participating in the campaign against
AIDS;
Servingas a focalpointforfederal organ
transplant activities;
Providing leadership in improving health
professions training;
Tracking the supply ofhealth professionals
and monitoring their competence through
operation ofa nationwide databankon
malpractice claims and sanctions; and
Monitoring developments affecting health
facilities, especially those in rural areas.
M+w/;&zfe3
2>
Office of Minority Health
Resource
Center
FOBox
37337
ia/ u
Washington, DC
20013-733?
1993
r
if \fl fl
Health Personnel in the United States
DHHSPublicationNo.P-OD-94-1
ii •Health Personnel in the United States •NinthReportto Congress •1993
Introduction
Legislation enacted in the 1970s requires theperiodic Thehealth care system ofourNation isbeing
submission ofreportsbytheSecretary ofthe Department fundementally altered as society struggles to reduce costs
ofHealthand HumanServices (DHHS) to theCongress on while maintaining quality and in someareas expanding
the status ofhealth personnel supply, distribution, and care. Undoubtedly, anychangeinhow health careis
requirements needed to provide adequate health care for delivered to the residentsofthis countrywillalso havean
theNation. The currentlegislativebasis for these reports effectonthepersonnel who deliver this care. Thisreport
isSection 792(d) ofthe Public HealthServiceActas presents primaryissues affecting the health professions.
renumbered by P.L. 102-408, the Health Professions The changing health care system, the major issuefacing
Education ExtensionAmendments of 1992. Section 792(d) health personnel, is discussed along with other important
was formerlySection 708(d) ofthe Public HealthService and emergingissues such as thedeclining interestin
Act, as amended byP.L. 94-484 and furtheramendedby primary carecareers, barriers to practicefor nurse
P.L. 95-623, P.L. 100-607and P.L. 100-690. In addition, practitioners, certified nurse midwives, and physician
separate legislationmandates reports to Congress on assistants, minority representation and minority health
nursing supply, distribution, and requirements (Section concerns, rural health personnel, nurse workforce issues,
951 ofP.L. 94-63asamendedbyP.L. 95-623), and onpublic and thevaryinghealth careneeds ofpersons withAIDS.
healthpersonnel (Section 794(c) ofthe Public Health Financingand reimbursementissues have and continueto
ServiceActasamendedbyP.L. 94-484and P.L. 95-623 and beexamined and analyzedby the Health Care Financing
renumberedSection793(c) oftheActbyP.L. 102-408). This Administration, Prospective Payment Assessment
ninthreport, required by the above noted legislation, Commission and the Physician Payment Review
presents information on issues affecting health personnel, Commission alongwith others. Therefore, despite the
and dataonthe health professions ofmedicine, dentistry, importance ofthese topics to thehealthworkforce, they
nursing, physician assistants, allied health, public health, arenot covered in this report.
pharmacy, optometry, podiatric medicine, chiropractic,
This ninth report also discusses occupation-specific
clinicalpsychology, clinical socialwork, and veterinary
issues that are affectingorcould affectan occupation's
medicine.
contribution to thedeliveryofhealthcareto the
This currentReportrepresentsanattempt to more population. The reportprovides information on
accuratelydepictthe status ofhealthcarepersonnelin the physicians, physician assistants, dentists, nurses, allied
United States. Muchofthe data onhealthcarepersonnel health occupations, optometrists, pharmacists, podiatrists,
in theUnited States thatappearedinprevious reports can chiropractors, clinical psychologists, clinical social
nowbe found ina sisterpublicationentitledFactbook: workers, public health, and veterinary medicine.
Health Personnel, United States. This report draws on data
from theFactbookand other information toidentifyand
discuss some ofthe universallyimportanthealth care
issues thatareexpected to affectthedeliveryofhealthcare
and the demand forhealth carepersonnel.
2993 •Health Personnel in the United States •NinthReportto Congress • 1
2 •Health Personnel in the United States •Ninth Reportto Congress • 1993
Table of Contents
Introduction 1 Individual Disciplines
Table ofContents 3 Physicians 53
Executive Summary 5 Physician Assistants 59
Dentists 63
Major Issues Nurses 67
State-level Health Care Reform Initiaitves, Potential Allied Health Introduction 73
Implications for the Health Workforce 13 Dental Hygienists 75
Primary Care Concerns 17
Physical Therapists 77
Analysis ofBarriers to Expansion ofClinical Occupational Therapists 79
Practice forNurse Practitioners and Certified
Speech-Language Pathologists
Nurse-Midwives 21
and Audiologists 81
Barriers to PhysicianAssistant Practice 27
Respiratory Therapy Personnel 83
Status ofMinority and WomenHealth Care
Dietitians 85
Personnel: Availability to Provide Careto
Special Populations 33 Diagnostic Imaging and Ionizing
Therapy Personnel 87
HealthCare in RuralAmerica 37
Medical Records Personnel 89
Preparing a Nurse WorkforceAppropriate for
Currentand Future Health Care Delivery 43 Clinical Laboratory Personnel 91
Health Care Services for Persons Public Health 93
with HIV/AIDS 47
Pharmacists 95
Optometrists 97
Podiatrists 99
:
Chiropractors 101
Clinical Psychologists 103
Clinical Social Workers 105
Veterinarians 107
ListofFigures and Tables 108
1993 •HealthPersonnel in the United States •Ninth Reportto Congress •3
4 •Health Personnel in the United States •NinthReportto Congress • 1993
Summary
Executive
Health Personnel in the United States: Ninth Report to Major Issues
Congress, 1993, is submittedby theSecretary ofthe
DepartmentofHealthand Human Services (DHHS) in State-level Health Care Reform Initiatives
response to directives ofseveral legislative authorities. The ongoing changes in the financing and delivery of
This report provides an overview ofprimary issues health care, especiallyattheStatelevel, hasbeen the
affecting the health professions, in particularthe evolving productofefforts to provide more comprehensive
health care financing and delivery system. Other coverage and reducethe rate that costs are growing.
important and emerging issues presented include the Undoubtedly, any change that alters the delivery ofhealth
declining interest in primary care careers; restrictive State care alsowillaffectthe personnelneeded to deliver this
practicelaws oracts thatcurrentlyprevent nurse care.
practitioners, certified nurse midwives, and physician
Several elements ofthe changing health care system
assistants fromusing theirfullrange ofskills and
will havea direct impactonrequirements forhealth
capabilities; the underrepresentation ofminorities in
personneland require changes inthemix and type of
healthprofessions and its impact onminority health; training theyreceive. Amongthese issues are the growth
causes ofshortages ofhealth personnel in ruralareas and
ofmanaged caresystems which relyheavilyon
associated problems ofaffordability and access to health
gatekeepers to ensure appropriate care, and increased
care; the need for anappropriatelytrained nursing
emphasis on preventive and primarycareservicesin order
workforce; and the varyinghealth careneeds ofpersons
to controlthe long-term costs resulting from inadequate
withHIV/AIDS. Also discussedbyprofession, areissues
access to care.
which affectthe supply, distribution, and adequacyofeach
discipline's abilityto provide health care. Information and Primary Care Concerns
data are presented on physicians, physician assistants,
dentists, nurses, allied health occupations, public health Most agreethataccess to primary care isbeneficial to
the overall health ofthepopulation and helps to control
personnel, pharmacists, optometrists, podiatrists,
costs. Forthis reason, expanding primary and preventive
chiropractors, clinical psychologists, clinical social
workers, and veterinarians. serviceshasbeena major objective ofthose seeking to
improve the existinghealth care system. Primary health
Thisreport'sformatis differentthanthat ofearlier care includes a comprehensive range ofpublichealth,
editions. Thereportrepresents anattemptto depictthe preventive, diagnostic, therapeutic, and rehabilitative
status ofhealth carepersonnelin theUnited Statesby services, the goals ofwhich areto preventpremature
identifyingtheissues affectingthem. Muchofthe data on death, disease and disability; preserve functional capacity;
healthcarepersonnel thatappeared in previous reports and enhance overall quality oflife. Awidevariety of
canbefound ina companion publication entitledFactbook: health care professionals either provideprimary medical
Health Personnel, United States. This reportdraws ondata careorcontributeto its provision. Theseinclude
fromtheFactbookand other sources to identify and discuss generalist physicians; some physician assistants and
importanthealthcareissues thatwill affectthe delivery of nurses, mostnotably nurse practitioners and certified
health careand the demand forhealth carepersonnel. nurse midwives; dentists; podiatrists; and to a lesser
degreepharmacists and a few allied health professionals.
1993 •HealthPersonnel in the United States •NinthReportto Congress •5
The domination ofoursystemby specialized health Status of Minority and Women Health Care
care providers and the dearth ofadequatelytrained Personnel: Availability to Provide Care to
primary care personnel have inhibited access to care and Special Populations.
helped escalate health care costs. Anymovement toward a While women have historically dominated the majority
moremanaged care approachto providing health care will ofnursing and allied health professions, the 1980s and
exacerbate the imbalancebetween theneed for generalists 1990s also sawthem contribute significantly to the growth
and the demand for these health care professionals as in traditionally male-dominated occupations such as
demand forprimary carepersonnel increases. To meet medicine, dentistry, and optometry. The growth rateof
future workforce needs, teaching hospitals, ambulatory minoritywomen in health care occupations has alsobeen
facilities, health professions schools, public agencies, and substantial, although suchwomen continue to representa
other private entities must assure that an appropriate very smallpercentage ofhealthprofessions graduates asa
numberand mix ofhealthprofessionals are trained in an whole. Black women, for instance, were solelyresponsible
environment conducive to preparing professionals to for increased blackrepresentation in medicine and
deliver primary care that is cost-effective, person-oriented, dentistry. The loss ofblackmale professionals in some
interdisciplinary, and community-based. fields and theirfailure to match thegains ofblackwomen
in others, represents a critical setbackthatneeds tobe
Barriers to Practice for Nurse Practitioners,
addressed. Similarly, while the growth ofHispanic
Certified Nurse-Midwives and Physician
women in allopathic and osteopathic medicine, dentistry,
Assistants
pharmacy, optometry, podiatry, and veterinary medicine
Concern over the lack ofprimary care practitioners, has exceeded that ofall women, their stillverysmall
coupled with ongoing efforts to increase access to care for numbers limit their availability to treatthe populations
theuninsured and improvepreventive services for all, has thatneed themmost. This is ofspecialconcerninthat
broughtfocus on theuse ofnurse practitioners (NPs), Hispanics are the fastest growing minority population in
certified nurse-midwives (CNMs), and physician assistants the United States.
(PAs) as a means ofprovidingprimary care. Currently, the
Manyofthenational health goals fortheyear2000 that
extentto which these health care professionals can provide
targetwomen and children in low-income and minority
primary care is governed by a variety ofrestrictiveState
groups depend on increasingthe supplyofwomen and
regulations and reimbursement policies. Thebarriers to
otherminority health careproviders tobridge the
practice affecting each profession are similar in manyways
language and cultural gap that ofteninhibits access to care.
butwith some differences thataffect their practice
Whilewomen will continue to increase their
environment. Thenetresult, however, is thatthe optimal
representationin many ofthe health careprofessions, an
use ofthesepractitioners isbeing compromised. States
inadequate supplywill serve as a constrainton the
regulatetheirrespective scopes ofpractice and in many
Nation's efforts to treatthe populations that need them
jurisdictions, despite adequate educational preparation,
NPs, CNMs and PAs areunableto perform the servicesfor most. The decliningnumbers ofblackmalegraduates in
some professions and the continued underrepresentation
whichtheyweretrained. The full utilization ofthe skills
ofother minorities indicaterenewed efforts areneeded to
ofthese practitioners would have a majorpositive effect on
increase therecruitment and retention ofthese
achieving the goals ofimproving health care delivery.
populations.
6 •Health Personnel in the United States •Ninth Reportto Congress • 1993
