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Allied Health Services: Avoiding Crises (1989)

Chapter: 4 Demand and Supply In 10 Allied Health Fields

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Suggested Citation:"4 Demand and Supply In 10 Allied Health Fields ." Institute of Medicine. 1989. Allied Health Services: Avoiding Crises. Washington, DC: The National Academies Press. doi: 10.17226/769.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 96 4 Demand and Supply In 10 Allied Health Fields MAJOR ECONOMIC, DEMOGRAPHIC, AND SOCIAL FORCES must be taken into account to assess the directions and magnitude of changes in the U.S. health care system and the implications of these changes for allied health employment. This chapter examines how each of 10 allied health fields is affected by these forces and how they will determine the demand for and supply of personnel for each field by the year 2000. The discussion that follows deals with national trends, even though local decision makers concerned with allied health practitioners may be faced with conditions that differ substantially from the national experience. The committee believes that its national analysis will be helpful to those who must draw conclusions about the future of allied health personnel in their own localities. The committee based its assessment of the future on several types of information. Bureau of Labor Statistics (BLS) projections of demand are the source of quantified demand information which the reader will find throughout this chapter (Bureau of Labor Statistics, 1987). To draw conclusions about demand the committee incorporated its own judgments about the impact of the many forces that drive demand. Assessments of supply were based on what would happen if the situation remained unchanged with respect to the rams at which individuals leave and enter the allied health work force. To that assumption were added assessments of the likelihood of the situation remaining unchanged. A final element in trying to foresee the future was the application of our limited knowledge of current demand and supply balances. Because decision makers must act even in the absence of complete data, the committee decided to make

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 97 assessments of future labor markets for allied health practitioners using BLS data. (Chapter 2 described the BLS data collection and projection process.) The committee advises readers to view the projections critically, in light of their inherent limitations. These projections should be interpreted not as a precise prediction of the future but rather as indications of the magnitude of change. The tools can then be used as a basis from which local and federal decisions makers can develop their own best estimates of the labor market. The committee emphasizes the importance of continued data collection to allow more precise projections. In some allied health fields the committee's assessment showed large discrepancies between demand and supply. The committee is not suggesting, however, that these gaps will necessarily occur. Rather, the market will eventually adjust so that a reasonable balance is achieved over time. If employers are sufficiently hard-pressed, they will raise salaries, which will attract more people to allied health careers. Employers whose ability to pass on costs is increasingly limited by prospective payment will also try to increase productivity and reduce the number of workers they employ as those workers become more expensive. Yet the committee is concerned that the market response will not be quick or creative enough to avoid some negative consequences—for example, erosion of the quality of care, service disruptions, and constraints on the ability of providers to make timely investments in new modes of service. Because these are serious consequences, the committee believes that it is important to try to anticipate them well enough in advance to forestall them if possible. Later chapters in this report are devoted to examining ways in which health care provider and educational institutions can protect themselves and, ultimately, patients from the costs associated with imperfectly working markets. The committee's comments about the way the year 2000 will look do not allow for major changes in the ways in which Americans pay for health care. If a major financing change should occur, the future of many allied health fields will be significantly altered. To illustrate the effects of financing changes, the committee applied the scenarios presented in Chapter 3 to each of the 10 allied health fields discussed in this chapter. In assessing future personnel demand for each of the 10 occupations, we have assumed that the current mix of fees for service and prospective payment (i.e., the mixed model scenario) will prevail for the next 12 years. As health care policy decisions are made at the national and local levels, however, planners must adjust their views of future allied health employment. To assist in this process, the committee has indicated how each profession might be affected by incentives characteristic of the access scenarios (which could include new state Medicaid entitlements or a nationally mandated benefits program) or the prospective payment scenario (which

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 98 could include a new state hospital rate commission or the extension of PPS to settings other than acute care hospitals). The committee has also attempted to alert readers to the significant trends in factors influencing supply—most often, the number of graduates and the number of educational programs. Yet labor force behavior is equally important. Unfortunately, there are only crude data on entrance into and exit from the allied health labor force; thus, the committee could make only very rough estimates of future supply. What is known is that even small changes in tenure in the work force can have a substantial effect on the future supply of allied health personnel. CLINICAL LABORATORY TECHNOLOGISTS AND TECHNICIANS Demand for Medical Laboratory Technologists and Technicians BLS predicts that between 1986 and the year 2000 the number of clinical and medical laboratory jobs for technologists and technicians will grow from 239,400 to 296,300, an increase of 24 percent. Although the growth rate is below that forecast for many other allied health occupations, it represents a substantial number (57,000) of new jobs. By comparison, the expected dramatic 87 percent increase in physical therapist employment represents only 54,000 new jobs. It must be remembered that the BLS data are based on employers' responses to questions about the numbers of people performing defined tasks. Respondents are not asked to distinguish licensed or certified personnel from those without such credentials. Clinical laboratories are in a period of rapid change. Technological changes are allowing the performance of tests in new settings and are also generating new tests. PPS has caused hospital managers to rethink the relative roles of in-house and reference laboratories. Changes in reimbursement have made physicians seek the benefits of providing office laboratory services. New settings for health care, such as ambulatory centers, are encouraging the establishment of laboratories in nontraditional settings. When analyzing these changes in terms of their impact on the demand for technologists and technicians, it is important to distinguish between changes that reduce demand, changes that increase demand, and changes that make no difference to manpower but only represent a change in location, techniques, or practice style. Because approximately 63 percent of clinical laboratory technicians and technologists are employed by hospitals (Table 4-1), changes in that setting will greatly influence the demand for those personnel and where they work. Indeed, a number of factors that are currently affecting the hospital lab-oratory work load may, in turn, affect personnel needs.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 99 TABLE 4-1 Major Places of Wage and Salary Employment for Medical and Clinical Laboratory Technologists and Technicians, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 239,400 296,300 employmentb Total wage and 238,400 100.0 295,200 100.0 salary employment Hospitals, public 149,800 62.8 160,000 54.2 and private Offices of 30,100 12.6 46,200 15.7 physicians Offices of 890 0.4 1,800 0.6 dentists and other health care practitioners Medical and 28,100 11.8 43,200 14.7 dental laboratories Outpatient care 5,300 2.2 13,000 4.4 facilities a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. These figures include 1,000 self-employed workers in 1986 and 1,027 in the year 2000 who are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. The introduction of PPS and the resultant reduction in occupancy rates, as well as the incentives it offers to provide less costly care, all affect hospital laboratories in several ways. Many hospitals have increased their use of reference laboratories for specialized tests, concentrating in-house laboratory work on widely used tests for which economies of scale can be achieved. Simultaneously, much preadmission testing is done on an out-patient basis, and the inpatient test mix has changed as more complex cases are admitted. According to the American Hospital Association, full-time-equivalent (FTE) employment in U.S. registered hospitals fell between 1983 and 1986, with medical technologist employment falling by 2.4 percent. FTE employment of other laboratory personnel fell by 5.3 percent between 1983 and 1985 and rose by 2.1 percent in 1986 (Bureau of Health Professions, 1985; American Hospital Association, 1987). A survey of the early impact of the diagnosis-related group (DRG) system on 122 hospital laboratories noted that 63 percent of hospitals experienced increased test volume in 1983. Increases in test volume occurred in only 32 percent of hospitals in 1984. The number of hospitals experiencing decreased test volume almost doubled from 24 percent in 1983 to 44 percent in 1984. The effect of the

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 100 decreases on staffing was observable. Fifty-seven percent of laboratories reduced employment after PPS—only 4 percent increased employment (Medical Laboratory Observer, 1984). These early changes that reduced demand did not continue, however. Current utilization and budgets are growing, and staff reductions have abated (Gore, 1987). Because the hospital census is thought to be a less reliable laboratory work load predictor than the severity of patient illness (Harper, 1984), one must look to the patient mix for explanation. With an aging population, the severity of illness is increasing. Although the number of lab items per discharge fell substantially during the early years of PPS, it rose 19.8 percent in 1985. Possible reasons for the upturn include increased case complexity, fewer opportunities to shift care to outpatient settings, and fewer opportunities to eliminate unnecessary services (Prospective Payment Assessment Commission, 1987). Medicare is not the only payer that is trying to reduce laboratory work. Other payers are becoming increasingly conscious of laboratory costs. For example, in 1987 Blue Cross and Blue Shield issued diagnostic testing guidelines for the appropriate use of 13 laboratory tests. Some of these tests are routine hospital admission or preoperative tests. While these guidelines were not associated with coverage rules, the recommendations are expected to be adopted by most of the plans and possibly by other insurers (Abramowitz, 1987). Efforts like that of Blue Cross and Blue Shield may herald a move from exhaustive testing to more targeted use of laboratory work. Technological change affects clinical laboratories in all settings. Today, while there is much discussion of automation in the laboratory—even robotics— that may reduce personnel needs or lower the skill levels required, concomitantly, there are potentially offsetting developments of new and complex labor-intensive, nonautomated tests. Technological changes, together with financial incentives and patients' desires, have stimulated physicians to make laboratory services available in their offices. Several surveys have been conducted of the extent of this practice. Estimates of the number of physician office laboratories range from approximately 80,000 to more than 250,000 (American Society for Medical Technology, 1986). BLS estimates that there are 30,100 technologist and technician jobs in physicians' offices, a number that is expected to rise to more than 46,200 in the year 2000. Observers close to the scene perceive diminishing enthusiasm for small physician office laboratories, possibly because they are not proving to be cost-effective and possibly because there are rising expectations of increased regulation to control quality. Two important questions for laboratory personnel demand emerge from the physician office laboratory phenomenon. One is whether physician

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 101 office tests are additional tests or substitutes for testing at other sites. Another is whether physicians employ clinical laboratory technologists or technicians. No evidence exists to answer the first of these questions. On the question of staffing, a literature review concluded that personnel other than technicians and technologists are more likely to do laboratory work in small or solo practices. Often, nurses are used. The larger the practice, the more likely that trained laboratory personnel are employed. One study found that more than 50 percent of group practices employed medical technologists (Frost and Sullivan, Inc., 1985). However, changes in the staffing of physician office laboratories may be on the way. Under its Omnibus Budget Reconciliation Act of 1987, congress enacted provisions that will require office laboratories that perform more than 5,000 tests on their own patients to conform to the Medicare conditions of participation developed for independent laboratories. This policy is scheduled to become effective in 1990. Technologists in independent practice are finding increasing employment opportunities as consultants to physicians who need help with calibration, quality control, test interpretation, more sophisticated procedures, and management of their office laboratories. Other new sites for laboratory work include HMOs and ambulatory care centers. Although 5,500 such centers are projected to be in operation by 1990, not all will employ highly trained lab personnel. At small centers now, nurses and x-ray technicians often perform routine tests, with cross-training conducted by the facility owner (Baranowski, 1985). The development of HMO laboratories is providing employment opportunities in a new setting, but this employment site should not be thought of as increasing the demand for personnel. Indeed, in the long run, as HMOs in competitive environments begin to seek new ways to control costs, it is reasonable to speculate that a reduction in demand for laboratory work may be brought about by curtailing superfluous testing. Future demand for clinical laboratory personnel has thus far been discussed as if changes will affect technologists and technicians equally. Whether this will actually be the case is unclear. Although incentives to reduce costs might lead one to expect that employers will seek to use less expensive personnel, at times more highly trained staff can be more cost effective. Similarly, although some technological changes, such as increased automation, may allow employers to expand their use of technicians or on-the-job trained personnel, others will require more highly trained staff. The trend in this field appears to be toward the increased use of higher level personnel with demand for lower level staff strengthened by difficulties in hiring more highly skilled workers. A 1987 survey of the American Society for Medical Technology members reports: ''Where hiring has occurred in the past two years... more technologists with the bachelor degree were hired than were clinical laboratory technicians (CLTs). Though some fa

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 102 cilities reported substituting specialists and more advanced personnel for entry- level practitioners, others reported hiring more CLTs and on-the-job trainees (OJTs)—to some extent as a result of a shortage of clinical laboratory scientists (CLS) professionals'' (Price, 1988). In sum, many of the changes occurring in clinical laboratories involve alternatives in the settings in which testing occurs. Some of these changes are spurred by financial considerations; some are driven by changes in the structure of the health care delivery system. Generally, these changes do not affect the demand for trained personnel in a major way because they do not have significant effects on the numbers or types of tests ordered. Although some extra testing is stimulated by the new settings, not all of the work is being done by clinical laboratory technologists or technicians. A concern about laboratory work that has surfaced in the popular press and that has also been voiced by the professional associations relates to quality. Reports of inaccurate PAP smear readings and false-positive AIDS tests have often focused on the laboratory personnel—a focus that could result in increased demand for licensed personnel or in the hiring of more personnel of all kinds to relieve pressures on staff. For the future, downward pressures on test volume caused by payers' attempts to reduce costs will be offset by upward pressures as new tests are developed and the aging population demands more services. Similarly, technological change will cause as much expansion as reduction in demand for trained personnel of all levels. Any growth in the demand for medical and clinical lab technologists and technicians will derive from a general expansion of the health care industry, the aging of the population, and an increase in some specific trends such as increased therapeutic drug monitoring, testing for substance abuse, and AIDS screening. Together, these upward pressures should lead to employment growth at a rate that could even exceed BLS's predicted growth of 24 percent to the year 2000. If either AIDS or drug testing becomes widespread, the demand for clinical laboratory technicians and technologists will increase further. This rate of increase could be reduced if, as is likely, tests eventually become more automated. Factors that would cause demand to change significantly and should therefore be monitored by those attempting to track the employment of clinical laboratory personnel include the following: • policies concerning AIDS screening; • policies concerning substance abuse testing; • technological change; • payers' attempts to control test volumes; • quality concerns; and • trends in state and federal regulation of laboratory settings.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 103 The three scenarios described in Chapter 3—mixed financing, prospective payment, and access—have some straightforward implications for clinical laboratory technologist and technician demand. Under the mixed model, growth in jobs is expected (as described earlier in this chapter)—probably in excess of 24 percent to the year 2000. If prospective payment becomes the dominant model, laboratory testing will come under scrutiny and incentives will ensure that all testing contributes to the clinical management of patients. Technological changes to improve cost-effectiveness and decrease personnel, both in numbers and skill levels, will be adopted. Yet demographic pressures will still exert upward pressures. In sum, demand will grow at a slower pace under the prospective payment model than under the mixed financing scenario. If a policy to expand access to health care occurs, additional individuals receiving care will increase the demand for laboratory personnel in all settings. Supply of Medical Technologists and Medical Laboratory Technicians The number of baccalaureate graduates in the field of medical technology has shown a downward trend since the end of the 1970s. In 1986 4,477 medical technologists graduated from accredited programs, a decrease of 28 percent from 1980. The number of accredited programs for medical technologists also decreased—26 percent over the 10-year period ending in 1986. Hospital-based programs closed most frequently, but closures in general occurred because of budget restrictions, the impact of PPS, a lack of qualified applicants, and a decreased need for laboratory personnel in the program's immediate geographic area (CAHEA, 1985b). During the past 10 years, total certificate medical lab technician programs decreased 69 percent. Yet associate degree medical lab technician programs increased over the 10-year period, and they increased more than four fold— from 38 programs to 214 programs. Between 1985 and 1986, however, there was a 5 percent drop (CAHEA, 1987a). The trend in certificate and associate degree personnel (technicians) is less clear than that for technologists. Although the 2,747 technician graduates in 1986 represent a 9 percent increase over 1980, graduations peaked at nearly 4,000 in 1984 and show a downward trend since then. There are two routes to becoming a technician. One is graduation from a certificate program. Only 817 medical laboratory technicians graduated from certificate programs in 1986, 24 percent fewer than in 1981. The other route is through associate degree programs, from which the number of graduates (1,930) in 1986 was an increase of 11 percent over those graduating in 1981 (CAHEA, 1987a).

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 104 At the start of this study, anecdotal evidence from educators and others pointed to a surplus of clinical laboratory technicians and technologists. But during site visits and discussions with knowledgeable observers toward the middle of 1987, the committee began to hear of managers who were having trouble hiring staff for clinical laboratories. Other reports confirm this change (Meyer, 1988), and other evidence supports the suggestion that the labor market is getting tighter. A recent survey of the directors of accredited education programs shows that between 1981 and 1986 the percentage of directors who considered the job market for laboratory technicians and technologists to be attractive increased substantially (Parks and Hedrick, 1988). An informal survey by the American Society for Medical Technology found 54 percent of constituent societies reporting an under-supply of clinical laboratory technologists. The undersupply figure was 38 percent for technicians (Meyer, 1988). A study commissioned by the Health Resources and Services Administration noted that shortages of medical technologists are occurring in some locales (Mathematica Policy Research, Inc., 1987). Statewide surveys in North Carolina (North Carolina Area Health Education Centers Program, 1987b) showed the vacancy rates for clinical laboratory staff increasing from 4.6 percent in 1981 to 16.5 percent in 1986. However, the salaries of technologists and technicians employed in hospitals between 1981 and 1986 increased 24 and 21 percent, respectively. Yet this increase is small compared with 18 other types of hospital employees—of these employees, only engineering technicians had an increase smaller than 21 percent (University of Texas Medical Branch, 1985, 1987). These figures suggest that the difficulties in hiring noted earlier in this paragraph may not have been evident in 1986. Conclusion Making statements about the likelihood of future balances or imbalances between the demand for and supply of clinical laboratory personnel is complicated by the multiple routes of entry into laboratory work. Laboratory workers may have 4 or more years of postsecondary education, or they may qualify for a job through a combination of shorter educational programs plus experience. Baccalaureate-prepared technologists need less supervision than other personnel, and they may hold a variety of higher level positions—for example, laboratory director, manager, consultant, and education coordinator for hospital schools. Technicians may have 2-year associate degrees or combine education and experience to become certified through a professional organization. Other laboratory workers are certified in special areas (e.g., cytotechnology or hematology), and still others may have specialist certification in such disciplines as blood banking or microbiology. Finally, there are large numbers of uncertified workers as indicated by the discrepancy between the BLS job count and the number of certified

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 105 personnel. These multiple routes of entry into a career in clinical laboratories make it difficult to assess the future supply of laboratory workers. Taking into account the comparatively modest expected growth in new jobs, and assuming that work force behavior and staffing patterns will not change radically, graduations from clinical laboratory programs should be sufficient to keep demand and supply in reasonable balance to the year 2000 if the rate of graduation is sustained at a minimum at its current level. The recent decline in the number of graduates must be halted, however. If this decline should continue, some improvements in salary and working conditions can be expected to bring supply and demand into balance. A number of factors make prognostications in this area tentative. If the growing numbers of biomedical technology firms become major users of laboratory personnel, thus diverting trained personnel from clinical laboratories, salaries and benefits would improve as employers compete for trained personnel. If personnel trained in such disciplines as chemistry and microbiology are no longer available to medical laboratories, there could be problems because these personnel are used to fill jobs when the labor market is tight. A significant change could come about as a result of employers using personnel differently. (For instance, laboratory managers may choose to substitute one level of personnel for another.) A great deal of flexibility is possible. Today, there is sometimes little or no differentiation in the way technologists and technicians are used, a situation that could change. If a 4-year degree becomes mandatory for licensure and licensure becomes a more widespread requirement; the demand and supply balance could be severely disrupted. There is increasing debate concerning the advantages and disadvantages of licensure whose purpose is to differentiate jobs according to academic qualifications. The scope of this study did not admit of a conclusion on this matter. As a final note, the clinical laboratory labor market seems to adapt rapidly to change—for example, changes in health care financing incentives. In the course of this study the reports of graduates having a hard time finding jobs were succeeded by reports of shortages of personnel. The reasons given for this turnaround are varied. Laboratories may have allowed staffing levels to decline too far in an overresponse to prospective payment. Laboratory volume may have risen faster than the supply. Others say that the level of stress at the work site has increased because of productivity pressures and the increased complexity of care. Fear of AIDS adds to the stress, and salaries are not high enough to compensate for such stress; consequently, people are leaving the field (Meyer, 1988). If these factors do generate an increase in the separation rate of workers from the labor force, it would have a significant negative impact on the supply of clinical laboratory technologists and technicians and necessitate greater market adjustments.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 106 DENTAL HYGIENISTS Demand for Dental Hygienists BLS estimates that in 1986 there were 86,700 jobs for dental hygienists. By the year 2000 this number is expected to have increased by 63 percent to 141,000 jobs. Such rapid growth is based on several considerations. First, BLS analysts consider employment growth in dental offices to be the most important element in generating jobs for dental hygienists because the vast majority (97 percent in 1986) is employed in that industry sector (Table 4-2). The BLS projection for dental hygienist employment is hampered by data collection problems that apply only to this sector. The survey on which the BLS data are based was sent to incorporated businesses only. A high proportion of dentists are not incorporated and therefore were not included in the survey. Dentists' offices provided nearly 460,000 jobs in 1986; this number is projected to reach 706,000 by the year 2000, a 53 percent increase. Contributing to this projected expansion is the BLS expectation that the number of working dentists will substantially increase by the year 2000 (from 151,000 to 196,000, almost 30 percent compared with 19.2 percent for all occupations). Moreover, these dentists are expected to sustain their level of use of dental hygienists. BLS analysts also believe that the entrance into the dental profession of younger dentists, who are taught how to make effective use of hygienists, will cause a slight increase in the ratio of hygienists to total dentist office staff. Other assumptions on which BLS has based its high-growth prediction include the continued spread of dental insurance, which will generate further demand for dental services; the aging population's need for dental TABLE 4-2 Major Places of Wage and Salary Employment for Dental Hygienists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 86,700 141,000 employmentb Total wage and 86,700 100.0 141,000 100.0 salary employment Offices of dentists 84,300 97.3 137,300 97.4 a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. Self-employed persons are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 107 services, part of which comes from the fact that people are now retaining their own teeth longer; and the "baby boom" generation's entry into middle age when periodontal disease becomes more prevalent. BLS notes that dental hygienists are often hired on a part-time basis. To be fully employed a hygienist will often take two or more part-time jobs. The projection of 141,000 hygienists' jobs by the year 2000 must therefore be substantially decreased to be translated into the number of hygienists employed. BLS analysts suggest that the reduction could be as high as 30 to 40 percent, which would result in an estimated 84,600 to 98,700 employed hygienists in the year 2000. This estimate is supported by data from a 1982 survey of 1,503 dental hygienists. The survey found that 29 percent of the respondents worked in more than one location indicating multiple jobs for most of this group. Six percent worked at three or more locations (Dental Hygiene, 1982). The demand for hygienists depends on the number of working dentists and the level of activity in their offices. The level of activity in turn depends on the prevalence of dental disease, the extent of dental insurance, and the willingness and ability of uninsured people to pay for dental treatment. The BLS assumption that the rate of growth of hygienist jobs will be double that of dentists depends on dentists being busy enough to want to employ hygienists. The prevalence of dental insurance has shown rapid growth (rising from 12 million to 81 million insured people between 1970 and 1980), and there is still untapped potential for further growth. But some analysts suggest that the rate of the spread of dental insurance has passed its peak. The "easy pickings" have been accounted for as most large, multistate employers now offer dental benefits (Bishop, 1983). The question remains whether the employment stimulation from increased dental insurance will be sufficient to offset the effect of such dental disease prevention as fluoridation and regular maintenance care. A major factor will be the extent to which dentists can expand the number of restorative treatments they perform. More than 70 percent of dental costs are paid out-of-pocket, and price is the barrier to dental care most often cited. As a result, only about half of the population visits the dentist each year (Grembowski et al., 1984). HHS's Bureau of Health Professions in a recent report noted the relationship between demand for dental care and national economic growth. The bureau used two different data series for dental expenditures to develop forecasts to 2015 using two scenarios of economic growth. For neither data set and scenario does future growth in dental expenditures reach the rate of growth observed from 1965 to 1985 (Bureau of Health Professions, Division of Associated and Dental Health Professions, 1987). Although the number of employed hygienists per dentist has increased substantially (from 4 per 100 in 1950 to 33.3 per 100 in 1986), the rate of increase since 1981 has been very slow (Bureau of Health Professions, Division of Associated

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 108 and Dental Health Professions, 1987). Only in the unlikely event that dentists become very busy will the momentum of the 1950s to early 1970s be regained. There is also reason to question whether the BLS estimate of 196,000 dentists in the year 2000 is too high. The number of graduates from dental schools peaked in 1982-1983 and is expected to continue to decline, reaching the level of the 1950s by the year 2000 (Solomon, 1988). A number of dental schools have closed largely because the perception of an oversupply of dentists has affected students' career decisions. The Bureau of Health Professions thus expects dentists to number 156,000 by the year 2000—40,000 less than the BLS estimate of dentist's jobs. There is clearly great potential for the increased use of dentistry. Some of this potential will be realized by the expansion of insurance and the growth of real income. Some expansion will stem from increased periodontal disease and other opportunities for intervention that arise from the new types of procedures needed to serve an aging population. Nevertheless, the committee questions whether these increases will be sufficient to allow dentists to employ hygienists at the rate predicted by BLS. The opportunities for hygienist employment outside dental offices today are limited by regulations that require them to work with dentists on site. Thus, populations such as the elderly in long-term care facilities and physically and mentally retarded people in institutions, whose access to dental care is limited by their lack of mobility, cannot be served by hygienists alone. Many in the dental hygiene profession are fighting the regulations that restrict their independence; yet if independent practice is achieved, it should not be viewed as creating demand unless the regulations are changed. In sum, although the number of jobs for dental hygienists will continue to grow, it seems unlikely that jobs will expand by over 60 percent by the year 2000—that is, twice the high rate of expansion predicted for dentists. The major factors that those concerned with future demand for dental hygienists should track include the following: • number and age of working dentists; • extent of dental insurance; • growth of real personal income; • dental disease patterns; • changes in the practice of dentistry that influence consumers' attitudes toward dental use (i.e., technological developments that may reduce the pain of dental treatment); • changes in staffing patterns in solo and group dental offices; and • progress toward independent practice. The three scenarios described in Chapter 3 are driven by changes in health care financing. Yet the financing of dental care is often independent

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 109 of the financing arrangements for other types of health care; therefore, the differences in demand for dental hygienists that may be caused by the financing- driven scenarios are small. Unless dental care becomes a usual component of the benefit packages in prepaid health plans, the expansion of the types of plans envisioned in the managed care scenario will have little impact on the demand for hygienists' services. Similarly, unless access to dental care is included in policies that increase access to health care generally, the demand for hygienists will be remain unchanged. Supply of Dental Hygienists The Council on Dental Education reported that in 1986, 198 accredited dental hygienist programs graduated 4,037 hygienists. The number of graduates declined gradually between 1980 and 1985, with 22.4 percent fewer people graduating in 1985 than in 1980, but showed a slight upturn in 1986 (American Dental Association, Division of Educational Measurements, 1987). Although most accredited dental hygienist programs require 2 years of study or its equivalent, the number of programs taking 3 or more years to complete has been increasing. In 1985, 33 percent of all programs had this longer requirement. Thus, the time it takes to produce a dental hygienist is increasing. Entry requirements are also being strengthened. In 1970, 80 percent of the programs required only a high school diploma. By 1985, 64 percent of the programs still used the high school diploma as the minimum qualification for acceptance, but 23 percent required some college courses. Representatives of the American Dental Hygiene Association and anecdotal evidence suggest that in some locations there are acute shortages of hygienists. In one such locality, after a survey confirmed that there were shortages, the dental association was willing to help the community college financially to create a new hygienist program. This collaboration is an example of the sort of adjustments that are often made to rectify labor market imbalances (McMahon, 1986). Conclusion Whether the number of dental hygienists available over the next 12 years will be enough to maintain a good balance between demand and supply depends in part on whether the decline in the number of dental hygiene graduates can be halted. If there is no further decline in graduations, there should be no need for major labor market adjustments. To halt the decline, however, some changes must take place; dental hygiene must become more attractive to prospective students. This change will occur if salaries are increased and working conditions improved. The resolution of some of

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 110 the tensions between dentists and hygienists (which are discussed in Chapter 7) may prove to be a key to improving working conditions. These changes would also decrease the number of workers leaving dental hygiene, and bring back into the work force some of those who have left. Relatively small adjustments now would avoid future dislocations and major adjustments later. DIETITIANS Demand for Dietitians BLS predicts that by the year 2000 there will be 53,800 dietitian jobs—an increase of 13,(600 jobs, or 34 percent, since 1986. This employment growth rate is the same as the rate BLS expects for respiratory therapists and speech pathologists but substantially below that expected for some of the other allied health occupations (e.g., physical therapists, dental hygienists, and radiologic technicians). The BLS data show that nursing homes and hospitals are the major sources of wage and salary jobs in this field (roughly 14 percent and 39 percent, respectively, as shown in Table 4-3). School systems, public health departments, HMOs, and ambulatory facilities also employ small numbers of dietitians, as do retail eating and dining establishments, publishers of nutrition and other magazines, diet counseling services, child care centers, and food manufacturers. BLS data indicate that there were 2,000 self-employed dietitians in 1986; this figure is projected to rise to 2,700 in the TABLE 4-3 Major Places of Wage and Salary Employment for Dietitians, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 40,200 53,800 employmentb Total wage and 38,200 100.0 51,100 100.0 salary employment Hospitals, public 14,800 38.7 16.700 32.6 and private Nursing and 5,400 14.0 9,000 17.6 personal care facilities a These percentages were calculated using unfounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the tables. b Total employment = wage and salary employment + self-employment. These figures include 2,000 self-employed workers in 1986 and 2,682 in the year 2000 who are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 111 year 2000; these figures constituted 5 percent of jobs in both years. A 1986 survey of members of the American Dietetic Association confirmed that hospital and extended care facilities are the primary employers, employing 54 percent and 10 percent of full-time members, respectively. The survey also noted that although only 3.7 percent of full-time workers were self-employed, more than 33 percent of dietitians who worked part time were self-employed (Bryk, 1987). BLS estimates that about 5 percent of dietitian jobs are filled by self-employed people. Dietitians thus differ from many other allied health occupations in their variety of employment settings and somewhat lesser dependence on hospitals. Analyzing employment in terms of factors that will either stimulate or depress demand indicates that overall modest growth can be expected, although it will probably be lower than BLS's projections. Factors that tend to restrain employment growth in the field include the slow growth of the hospital industry. Indeed, it is notable that FTE employment in hospitals decreased even before the introduction of PPS and that the decrease accelerated thereafter (Bureau of Health Professions, 1985; American Hospital Association, 1987). However, all of this reduction in hospital employment does not necessarily reflect the reduced use of dietitian services by hospitals. Hospitals can contract for services rather than employ dietitians directly. Similar changes may be taking place in nursing homes. The move to out-of-hospital services is likely to produce a modest shift of employment to ambulatory clinics but no significant change in the number of dietitians employed. Although prospective payment for hospital care is generating an increased need for home care, the growth of dietitian employment in home care is inhibited by Medicare reimbursement regulations that prohibit dietitians from billing for home visits. Instead, they are included in the administrative expenses of home health agencies. A study charged with making reimbursement recommendations to Congress noted that, although dietary therapy is important and necessary for a wide range of diseases, the present reimbursement approach is adequate (Health Care Financing Administration, 1986a). Another factor that can constrain the growth in demand for dietitians is the extent to which other professionals such as nurses or health educators are thought to provide substitutable services. In the current environment of price competition, except for some specific tasks, dietitian duties could conceivably be eliminated or performed by other personnel. There are currently no data on this phenomenon, however. On the other hand, there are factors today that are increasing demand. One is the increased use of high-technology nutrition services such as enteral and parenteral nutrition (feeding through tubes and veins) in institutional as well as home settings. (Here, too, however, other professionals such as pharmacists compete with dietitians to provide services.) Further

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 112 more, the aging of the population and the increased hospitalization of patients with complex problems requiring nutritional intervention should stimulate demand. Another important upward pressure on demand is the societal value now being placed on nutrition. For example, the fitness movement includes a consciousness of the importance of good nutrition in health promotion and disease prevention. Grocery stores and magazine publishers employ dietitians to advise on the nutritional content of foods and to develop recipes. Individuals are willing to pay out-of-pocket for nutritional consultation that is available through independent practitioners or as a package with other services. Health care providers who compete with each other to attract consumers are increasingly aware of the importance consumers place on nutritional advice in obesity and cholesterol control. Also associated with disease prevention and the high cost of treating acute conditions is the use of nutrition in preventing coronary disease, diabetes, obesity, hypertension, atherosclerosis, and arthritis. Providers at risk for the cost of care, such as HMOs, can be expected to use nutritionists to reduce the likelihood of acute illness. Public health departments are also concerned with preventing disease and thus provide nutritional services through such programs as the Special Supplemental Food Program for Women, Infants, and Children (WIC). One survey identified 22 state health agency program areas that were expected to use nutrition services and noted expanded nutrition services by both local and state public health agencies (Kaufman et al., 1986). Although public health funding is limited, it appears that a new appreciation of the value of nutrition services is generating an increase in their use. The aging of the population will drive up the demand for dietitians to care for the complex nutritional needs of nursing home patients. The BLS data reflect this expected increase, projecting 3,600 more jobs in nursing homes in the year 2000, which will increase the proportion of dietitian jobs in that setting from approximately 14 percent of all jobs in 1986 to 17.6 percent in the year 2000 (see Table 4-3). Overall, employment growth expectations for dietitians are well above the national average but are moderate to modest when compared with some other allied health fields. The hospital sector is not likely to be a major source of new demand. Independent practitioners contracting with hospitals and nursing homes do not represent new opportunities but a different employment pattern. On the positive side, public demand for nutritionists' services should create some new employment. This employment will most likely occur in settings that market such services directly to consumers and in settings in which the dietitian's role in health promotion and disease prevention is valued. However, the increased potential for employment in any of these sites will create only a minor overall increase in demand.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 113 The following is a list of factors that are important determinants of demand for dietitians: • consumer desire for nutritional advice; • new places of employment such as the food industry and publishing; • trends in private practice; • trends in the substitution of other professionals (nurses, health educators, home economists, pharmacists) for dietitians; and • interest in and payment for health promotion/disease prevention and perceptions of the importance of nutrition. The three scenarios that were described in Chapter 3 have different effects on the demand for dietitians, mainly through their role in health promotion and disease prevention. Scenario 1: The Mixed Model Moderate growth in the demand for nutritionists' services would occur through the expansion of employment opportunities created by the aging of the population, direct consumer demand for services, and hospital admissions of patients with complex problems. Scenario 2: Prospective Payment Although hospital utilization of dietitians would be reduced under this scenario, overall employment would be less affected than in other allied health occupations that are more dependent on hospital employment. The growth of HMOs and managed care systems that emphasize health promotion and disease prevention, as well as marketing to consumers, would increase the demand for nutritional services. Under this scenario, physicians working outside managed care systems would increase their scope of services and employ or contract for dietetic services in their offices. Consumers would adopt the attitude of health care providers emphasizing wellness and would therefore be eager for nutritional services and information from all sources— food labeling, publications, independent practitioners, and the like. Scenario 3: Access Policies that enhance access to care could stimulate dietetic services in several ways. By relieving financial pressures caused by low occupancy rates, hospital demand would revive. Hospitals would then be able to hire staff to provide services that were considered marginal in times of fiscal constraint. In addition, access to services for groups with special nutritional

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 114 needs, such as migrants and pregnant teenagers, would stimulate the demand for dietitians employed in primary care settings. The increment in demand overall would be only moderate, however, and substantially less than for the occupations more closely tied to acute illness. Supply of Dietitians There are three main ways to become a registered dietitian. One is to graduate from a baccalaureate program in an appropriate field of study and complete an internship; the second is to complete a graduate program in dietetics. Because internships are in short supply (only about 900 per year, compared with approximately 3,000 students who need them), some graduates of dietetic programs do not proceed to registry. The third course circumvents the internship requirement: students complete graduate degrees that do not require internships and proceed to registration by that route. Coordinated undergraduate programs combine academic course work with approximately 1,000 hours of clinical experience. Since 1980 the number of newly registered dietitians has fallen 20 percent from just over 3,000 to just under 2,400 (American Dietetic Association, 1987). The consensus for the past few years is that there has been a surplus of dietetic professionals (American Dietetic Association, 1985). This conclusion should be only tentatively modified by the salary increase of 29 percent between 1981 and 1986 received by dietitians who were employed in hospitals—an increase comparable to that received by pharmacists and staff nurses, who are perceived to be in short supply (University of Texas Medical Branch, 1981, 1986). Because no other evidence of shortage or surplus was found, it is assumed that a reasonable balance exists today. Conclusion If the annual number of new registrants is maintained at around the 1986 level of 2,400, or if only a very modest decline occurs, the committee estimates that demand and supply for dietitians will be in balance up to the year 2000. However, halting the current decline in registrations will require both that academic programs remain viable and that health care employers and educators act aggressively. Employers need to offer jobs that are as attractive as their competitors for dietitians outside the health care industry. In addition, dietetics must be made as attractive as other possible careers. Yet it is not always possible to discern differences between some of the jobs that registered dietitians hold and the jobs held by other types of dietary personnel—for example, nonregistered graduates of dietetic programs and graduates of home economics or food service management programs. It

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 115 is possible that these latter groups will be used in greater numbers if employers find it difficult to hire registered dietitians. EMERGENCY MEDICAL TECHNICIANS Demand for Emergency Medical Technicians As it does for other fields, BLS estimates the number of paid jobs for emergency medical technicians (EMTs). Because emergency medical technology jobs are often filled by volunteers—by a ratio of 2 to 1 in 1984—the BLS stresses that its estimates cover only paid EMTs. The bureau estimates that there were 65,200 paid EMTs in 1986, a small number of whom had received the advanced training and field experience required to become an EMT-paramedic (EMT-P). The BLS data exclude volunteers and do not distinguish among the three levels of EMTs. The lower (basic) level EMT-A and the upper level EMT-P have existed since the late 1970s; in 1981 an intermediate level (EMT-I) was added to the available certifications (McKay, 1985). By the year 2000 the number of paid EMTs is expected to increase by 15 percent to 75,000. This growth is substantially below that of the other allied health fields discussed in this chapter and below the expected 19 percent growth in the total U.S. labor force. BLS notes that this slow growth in employment will be shaped by conflicting forces. On one hand, population growth, especially the proportion of the elderly, is expected to spur demand for EMTs. Progress in emergency medicine is also expected to increase demand. On the other hand, the rising cost of training and equipment coupled with the termination of federal start-up funds for community emergency medical services, taxpayer resistance to increased local government expenditures, and the availability of unpaid volunteers are factors that are likely to constrain job growth for paid EMTs (Bureau of Labor Statistics, 1986). Of the 10,000 new EMT jobs expected by the BLS in the year 2000, state and local government will account for almost 40 percent (Table 4-4). It has been noted anecdotally that the governments of major metropolitan areas throughout the United States have been examining their existing emergency medical services and contrasting the benefits of contractual services versus government-run services. Any decisions to use contractual services will, of course, lessen the expected growth of jobs within government, but overall demand should not be much affected by a change in employer. There also appears to be movement toward the privatization of emergency medical services. Along with large companies that provide services on a contractual basis, there has been growth in physician-owned ambulance

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 116 services and privately run emergency departments that operate their own ambulance services. BLS foresees that 2,400 new EMT jobs—nearly a quarter of all newly created jobs—will be available in privately owned ambulance services. TABLE 4-4 Major Places of Wage and Salary Employment for Emergency Medical Technicians, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 65,200 75,000 employmentb Total wage and 65,200 100.0 75,000 100.0 salary employment Local and 25,500 39.2 27,900 37.2 interurban transit State and local 24.500 37.6 29,700 39.6 governmentsc Hospitals, public 14,600 22.4 16,200 21.7 and private a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. c These figures do not include government hospitals and schools. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. BLS also predicts that hospital employment of EMTs will increase by 11 percent. This projection is based on a determination that hospitals, expecting emergency medical services to be profitable, will compete with private ambulance services. Yet anecdotal evidence suggests that no trend toward hospital-managed emergency services is developing. Although some hospitals have been entering the market, others have tested it and stepped away. However, there is evidence (also anecdotal) that EMTs are sometimes employed in hospital emergency department—the nurse shortage being a major factor in decisions to employ EMTs (McKay, 1985). The BLS projection does not differentiate between jobs for the basic EMT versus those for the more highly trained paramedic; yet the availability of volunteers makes such a differentiation important. Technological developments have virtually transformed ambulances into mobile intensive care units that employ technicians with skills in defibrillation, endotracheal intubation, pharmacology, and other aspects of intensive care. Usually, volunteer technicians are not adequately trained to appropriately assume that level of care (Smith and Bodai, 1985). As the use of advanced life-support techniques becomes more commonplace, the demand for paramedics is likely to increase sharply relative to other levels of EMTs. Vol

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 117 unteer technicians typically have only basic training and so provide little or no competition for jobs requiring advanced skills. However, the lower level basic EMT seeking a job must compete with the volunteer. Increased demand for the basic EMT can be expected from the nonemergency transportation sector. One consequence of Medicare's PPS has been the early discharge of elderly patients. Patients still in need of nursing care are often transported in ambulances to nursing homes. Basic EMTs are employed to care for the patients in transit. Supply of Emergency Medical Technicians EMTs are trained in a variety of settings. Accredited educational programs for EMT-Ps came into being in 1982 and have graduated a total of 2,466 technicians through the 1985-1986 academic year (CAHEA, 1984, 1986, 1987a; Journal of the American Medical Association, 1983, 1984, 1985). A greater number of paramedics are trained in unaccredited programs. According to the National Registry of EMTs, there were 440 EMT-P training programs in 1985, of which only 15 were accredited. The 1985 National Emergency Medical Services Data Summary lists a total of 5,059 EMT-Ps being trained annually; however, only 42 states and the District of Columbia responded to the survey. Three large states—California, New York, and Texas—were not among those reporting figures. Thus, the number of EMT-P graduates is substantially higher than 5,059. The same survey shows a total of 83,650 basic EMTs being trained annually (National Emergency Medical Services Clearing House, 1985). Observers of the field say that paramedics are in very short supply. The opportunity cost of training and rapid burnout discourages entry into the field. There is also very rapid job turnover among EMTs. The average volunteer is active for only 5 to 6 years (Lucash, 1983). The turnover rate among full employed EMTs is said to range between 20 and 40 percent. The committee was frustrated by the lack of reliable data on the basic characteristics of the EMT work force and on the forces that influence their training and use. These characteristics and forces appear to vary among communities and are also changing rapidly. This field exemplifies the problems of trying to predict the future in the absence of a well-organized professional association that collects or stimulates the collection of manpower information. This also makes it difficult for BLS to make a precise and useful occupational classification. Lacking data on the numbers and trends in training of EMT-Ps and basic EMTs, it is impossible to make an assessment of future trends in the balance between demand and supply. Anxiety about the quality of emergency services has begun to surface in some cities. Should this anxiety

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 118 spread, the demand for more highly trained technicians could put pressure on the supply pipelines. Data collection could help clarify the facts that decision makers need to ensure the smooth running of emergency medical services. As recommended in Chapter 2, an interagency task force could work toward a data collection plan. MEDICAL RECORD ADMINISTRATORS AND TECHNICIANS Demand for Medical Record Technicians BLS projects that the number of jobs for medical record technicians will grow by 75 percent from 39,900 in 1986 to 69,800 in the year 2000. This rapid growth exceeds the rate predicted for any of the other allied health fields discussed in this report, except for physical therapy. Unfortunately, BLS does not project employment for medical record administrators. The expectation of rapid growth in jobs for medical record technicians is predicated on the increasing importance of the medical record function in financial control and billing. BLS analysts believe that this high rate of growth is likely because health care payers are requiring more detailed and more accurate medical records for reimbursement purposes in all settings, including outpatient facilities. In the past, many jobs in medical record departments and physician offices were filled by individuals trained on the job to perform coding and transcription tasks. But increasing payer demands have made the work so complex that staff trained on the job are no longer adequate. Thus, a surge in demand for certified technicians is expected. This analysis can be substantiated to a great extent. Data from the American Hospital Association show that medical record technician employment in U.S. registered community hospitals grew by 6 percent in the 2 years following the introduction of PPS, compared with 2.5 percent in the 2 earlier years (Bureau of Health Professions, 1985; American Hospital Association, 1987). Employment of the more highly qualified medical record administrators expanded by 2.1 percent in both the 2 years before and the 2 years after PPS. The American Medical Record Association (AMRA) studied the impact of PPS on a sample of 775 hospital medical record departments. The study's findings noted that 93 percent of the respondents agreed that prospective payment required greater expertise, and 75 percent noted more stringent hiring standards (Schraffenberger, 1987). Another AMRA study attributes at least some of the observed increases in numbers of employees and salaries to the advent of PPS (Bernstein, 1985). Whether this translates into the hiring of more credentialed practitioners is not stated, but another AMRA survey noted that a ''substantial percentage'' of

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 119 hospital record departments filled coding positions exclusively with credentialed professionals (Whitlock and Whitmore, 1987). Although the impact of PPS is one factor in accelerating the demand for medical record technicians, the role of medical records in utilization review and quality control must also be noted. The complexity of medical record systems that interface with utilization and quality review systems and with physician office linkages raises the required skill standards for staff, in addition to generating an increased demand for personnel. The automation of medical record departments has been rapid. In 1981, 28.3 percent of hospitals sampled by Shared Data Research had some automation. By 1984 this figure had risen to 48.1 percent (Packer, 1985). Undoubtedly, the close connection between medical records, billing, and cash flow encourages automation to speed payments. The questions of whether—and if so, when—the use of computers will slow down the demand for medical record technicians are not clear. However, retention of the paper medical record appears to be common because computer technology cannot completely substitute for the tangible form. (For example, a paper record is needed if litigation occurs.) Even official attempts to simplify medical record tasks seem to backfire. The UB-82 form, an attempt to create a form that all payers could use, only increased the work load for coders and resulted in the hiring of additional staff (Burda, 1984). In 1984 about three-quarters of all medical record technician jobs were in hospitals. The pattern of employment is changing, however, and BLS expects that it will continue to change. By 1986 only 61.5 percent of all jobs were in hospitals. By the year 2000 BLS expects hospital employment to have fallen to about 58 percent and employment in outpatient facilities to have risen from 9 percent in 1986 to almost 13 percent in the year 2000 (Table 4-5). The demand for medical record technicians from nonhospital health care providers is expected to rise for many of the same reasons that demand from hospitals is rising. Payers' documentation requirements are increasing for all settings, and documentation for billing purposes is tied to medical records. In sum, the demand for qualified medical record personnel is related to the amount and sophistication of required documentation for purposes that include reimbursement of services, malpractice protection, and quality of care considerations. The ongoing changes in reimbursement policies, with payers increasingly concerned with the appropriate use of services, will continue to generate steady increases in the demand for medical record personnel. Yet the rate of increase is likely to slow as record systems become better established. Thus, the greatest increase would occur at the beginning of the period we have been considering. BLS's estimate of a major (75

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 120 percent) overall increase in demand to the year 2000 is supported by the expansionary forces at work. TABLE 4-5 Major Places of Wage and Salary Employment for Medical Record Technicians, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 39,900 69,800 employmentb Total wage and 39,900 100.0 69,800 100.0 salary employment Hospitals, public 24,500 61.5 40,800 54.2 and private Nursing and 4,500 11.2 7,500 10.8 personal care facilities Outpatient care 3,600 9.1 9,000 12.9 facilities Offices of 2,400 6.0 5,800 8.3 physicians a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. For those looking to the future, the following are important factors that should be monitored: • changes in payment systems and regulation; • growth of new employment opportunities in out-of-hospital settings; • impact of automation; and • new uses of the information contained in medical records. The three financing-driven scenarios described in Chapter 3 have direct and fairly simple implications for the demand for medical record technicians. The spread of prospective payment stimulates demand as the amount and complexity of documentation tied to payment increase and facilities use the medical record to review utilization as a part of cost-control efforts. Under the access scenario, demand increases in proportion to the amount of additional service generated. Demand for Medical Record Administrators Because BLS does not project demand for medical record administrators, there is no estimate of employment for the year 2000. The number of persons with a bachelor's degree in medical record administration is relatively small: approximately 9,500 people have graduated with the credential since 1970 (CAHEA, 1979, 1980, 1981, 1982, 1983, 1984, 1985a,

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 121 1986, 1987; Journal of the American Medical Association, 1984; Council on Medical Education of the American Medical Association, 1972, 1973, 1974, 1978). It is difficult to determine how employers view the difference between the more highly educated administrator and the technician. Roughly half the directors of medical record departments have the administrator credential, and half are registered technicians (Amatayakul, 1987). In cases in which medical record technicians are department directors, there is no way to determine whether this occurs because administrators were not available or were too expensive, or because technical-level skills are adequate for this work. Given this uncertainty, it is not possible to discuss differences in future demand for medical record administrators and medical record technicians. Supply of Medical Record Personnel Although graduations of both medical record administrators and medical record technicians have increased since 1980—20 percent for administrators, 27 percent for technicians—the increase shown by technicians has been steadier. Together, the two types of programs produced almost 2,000 graduates in 1986, of which about 46 percent were at the administrator level. The number of accredited technician programs grew rapidly in the late 1970s. Today, there are 87 programs, but the last 6 years saw the establishment of only 7 percent of them (CAHEA, 1987a). Some schools have closed, in part because of a decline in the applicant pool and in part because of budget problems and accreditation requirements (CAHEA, 1987b). Graduates of accredited programs do not represent the total supply of workers to fill jobs in medical record departments. Substantial numbers of the employees who "compile and maintain medical records" (the BLS job description) are trained on the job to do transcription and other tasks for which extensive training is not necessary. Determining whether there is currently a good balance between the demand for and supply of medical record administrators and technicians is complicated by the availability of workers who can be trained, if necessary, to fill the medical record jobs requiring lower level skills. It seems unlikely that widespread reports of job vacancies will occur if employers can concentrate their use of skilled practitioners where needed and fill in with others. Yet the findings of one salary survey suggest that employers may be struggling to fill jobs with qualified practitioners. Between 1981 and 1986 the starting salary for medical record administrators in hospitals increased by 45 percent—a substantially greater increase than occurred for any of 19 other types of hospital employees. Medical record technicians did less well (possibly because they are more available or possibly because they are more vulnerable to substitution). Their gain was 24 percent, an

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 122 increase exceeded by half the group of hospital employees (University of Texas Medical Branch, 1981, 1986). Conclusion If one assumed that graduates from accredited schools were the only source of medical record technicians and that demand would grow at the rapid rate predicted by the BLS to the year 2000, there would not be enough trained technicians to fill the jobs. These assumptions are not realistic, however. They are offered merely as a starting place from which to indicate how the labor market is likely to work. First, workers who have not had the benefit of accredited education do fill jobs in medical record departments and will continue to do so to some extent. Nevertheless, current trends indicate that the knowledge and skill level needed in medical record positions are rising and will continue to rise in the foreseeable future. Therefore, a greater proportion of trained practitioners will be needed to fill current and new jobs. Graduations of administrators and technicians show a rising trend, and the number of accredited programs is growing, albeit slowly. Thus, it is likely that the supply of trained technicians will grow—and not remain constant as in our initial assumption. In sum, to avoid a shortage of medical record personnel from now until the year 2000, the labor market must make major adjustments that will cause medical record technology to be viewed as a more promising career than it is today. One likely change is that the investment in medical record education will be recognized in greater pay, status, and task differentiation—there are indications that this is already happening. As such changes occur, the number of specially trained workers should grow, enabling employers to continue to phase out those with only on-the-job training. OCCUPATIONAL THERAPISTS Demand for Occupational Therapists BLS estimates that jobs for occupational therapists will increase by 52 percent between 1986 and the year 2000, rising from 29,400 to 44,600 jobs. This predicted high growth rate is still lower than that predicted for physical therapists, in part because a greater proportion of occupational therapists are employed in the slow-growing educational sector. In 1986 just over 36 percent of occupational therapist jobs were in hospitals; 13.2 percent were in government employment (excluding educational institutions and hospitals). BLS classified 4.5 percent of jobs as being in "offices of other practitioners"— that is, offices of practitioners other than physicians (including osteopaths) and dentists and including the offices of independent practice occupational therapists (Table 4-6).

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 123 TABLE 4-6 Major Places of Wage and Salary Employment for Occupational Therapists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs 1986 Jobs, 2000 Total 29,400 44,600 employmentb Total wage and 26,300 100.0 40,000 100.0 salary employment Hospitals, public 9,600 36.3 13,700 34.3 and private Outpatient care 16,000 6.3 3,400 8.6 facilities Offices of 400 1.5 760 1.9 physicians Offices of other 1,200 4.4 3,100 7.9 health care practitionersc Educational 4,400 16.7 5,100 12.8 institutions, private and public Federal, state, and 3,500 13.2 4,100 10.2 local government institutionsd a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. These figures include 3,000 self-employed workers in 1986 and 4,644 in the year 2000 who are not allocated by place of employment. c Offices of health practitioners other than physicians (including osteopaths) and dentists. The figures also include offices of occupational therapists. d These figures do not include government hospitals and schools. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. BLS analysts identified a number of factors they expect will drive this predicted strong growth in employment. These factors include the trend of occupational therapists increasing their share of hospital employment; federal legislation involving services for handicapped children, which will increase employment in the area of school services; and increases in private practice opportunities generated by improved reimbursement. These factors will undoubtedly stimulate the demand for occupational therapists. Hospitals provide more than one-third of the available jobs in the field today, and the growth rate in this sector alone will have an important influence on the demand for occupational therapists. Occupational therapy is one of the few allied health groups that sustained employment growth in the 2 years after the introduction of PPS. FTE employment in U.S. registered hospitals increased by 10.7 percent between 1981 and 1983 and by 22.7 percent between 1983 and 1986 (Bureau of Health Professions, 1985; American Hospital Association, 1987). Some of this growth in hos

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 124 pital employment results from more hospitals offering occupational therapy services. Between 1980 and 1983, 268 hospitals added occupational therapy to their list of services, and a 1984 survey of hospital chief executive officers indicated that 18 percent planned to add or expand their occupational therapy services (American Occupational Therapy Association, 1985). Yet despite this history of strong growth, unless occupational therapy can be established as enhancing the early discharge of patients, the service could be vulnerable to cuts if hospital operating margins continue to be threatened. The demand for occupational therapists in prolonging the independence of AIDS patients could, in the future, generate demand for more occupational therapists. The role of occupational therapy in caring for the mentally ill in hospitals and in such settings as halfway houses can only be inferred from the BLS data. Psychiatric hospitals and psychiatric units of general hospitals are included in the hospital industry estimates, and occupational therapy services are often provided by contractors to, for example, halfway houses. However, occupational therapy has a long history as part of the team that cares for people with mental illness. Future demand from this sector of the health care system will be determined by mental health insurance coverage, the availability of publicly sponsored programs, and the evolution of treatment modalities for mental illness. What the data do not show is the extent to which employment growth in the field was sustained by the use of occupational therapists in hospital-based rehabilitation facilities, which have not come under PPS. According to the American Occupational Therapy Association's 1986 member survey, roughly 40 percent of hospital employment was in rehabilitation (American Occupational Therapy Association, 1987). The demand for occupational therapists in rehabilitation care is being stimulated by two factors. One is the discharge of patients from the acute care hospital to rehabilitation facilities to escape the PPS setting. The second, effective July 1987, is the addition of occupational therapy as a Medicare-covered rehabilitation agency service under Part B of the Medicare regulations (Scott, 1987). Medicare has also made other changes that will stimulate the demand for occupational therapists. Since July 1987 occupational therapy has been covered by Medicare Part B for service in skilled nursing facilities. This provision will allow providers to bill Medicare for occupational therapy services and will offer a new incentive for therapists to establish practices that market services to nursing homes. Home health care is another area of potential growth in demand for occupational therapists. The number of occupational therapists employed by certified agencies rose from 410 in 1983 to 3,979 in 1985, then dropped to 1,997 in 1986 (National Association for Home Care, 1987). In view of the upward pressures on occupational therapy service demand in the home,

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 125 it seems likely that some of the decrease is due to increased contracting for services. In 1986 new federal legislation (Public Law [P.L.] 99-457) was enacted that should increase demand for occupational therapists by the educational sector. This legislation increased federal funds to encourage state departments of education to provide special education and related services to handicapped preschoolers. Under the act, occupational therapy would be available to children who needed it in order to benefit from special education (American Occupational Therapy Association, 1986b). Other factors that tend to generate a demand for occupational therapists are related to demographic and disease changes. These changes include the increased survival of head trauma victims and low-birth-weight neonates. In 1973 no respondent to a survey by the American Occupational Therapy Association reported head injury as being among the most frequently seen problems. By 1986, 3.3 percent reported head injuries as the problem seen most frequently. Similarly, developmental disabilities (excluding mental retardation) have now become the most frequently seen problem, rising from 5.8 percent in 1978 to 16.5 percent in 1986 (American Occupational Therapy Association, 1985, 1987). In addition, the aging of the population has implications for greater use of occupational therapy in nursing homes, home care, and hospitals. It is estimated that about 17 percent of occupational therapy work is done with elderly patients and that large numbers of nursing home residents would benefit if occupational therapy were available (National Institute on Aging, 1987). Yet significant increases in occupational therapy's role in nursing home care are unlikely unless financing becomes more generous or regulations require them. Some disease patterns and financing moves should generate downward pressures on the demand for occupational therapists. For example, the incidence of cardiac disease and cerebrovascular accidents (whose sequelae are commonly treated by occupational therapists) is declining—although this will be offset to some extent by increased survival rates. On the financing side, efficiency incentives and competition are expected to continue to force facility managers to seek ways to reduce costs. Occupational therapists may be asked to increase productivity, or they may be vulnerable to reductions in employment by managers seeking to trim staff. In sum, the upward pressures on occupational therapist demand are expected to exceed and overwhelm downward pressures. Growth in demand will be greater outside the acute care hospital sector and should be of the order of magnitude predicted by BLS. One uncertainty that could substantially decrease demand in the future is the issue of Medicare payment for rehabilitation services. Although the extension of PPS on a diagnosis basis in rehabilitation is unlikely, the introduction of some sort of incentives for economic restraint are slated for implementation.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 126 Factors that should be monitored by those interested in assessing the demand for occupational therapists include the following: • Medicare payment and regulations for rehabilitation services; • growth of the hospital sector; • demographics concerning school-age children and programs for handicapped children; • participation of home care and other long-term care services; and • the roles of competing occupations such as recreational therapists. Our three scenarios, which reflect three different health care funding environments, affect occupational therapist demand mainly through the impact of the scenarios on hospital care. Scenario 1: The Mixed Model This scenario foresees the continuation of most of the trends in evidence today. The demand for occupational therapists to work in hospitals and rehabilitation facilities would continue to increase steadily, assuming that the latter remain free of PPS. The demand from skilled nursing facilities and home care agencies would also show modest but steady growth as more older people need services. Scenario 2: Prospective Payment The financial incentives incorporated in the prospective payment scenario would create downward pressure on the demand for occupational therapists. Under this scenario, managers in general hospitals would scrutinize cost- effectiveness studies for evidence that occupational therapy decreases the length of hospital stays and is cost-effective. Similarly, large employers would include occupational therapy in benefit packages if it were shown that it speeds the employee's return to work. Lacking such evidence, growth in acute care hospital and outpatient employment would be negligible. Under this scenario, rehabilitation facilities would also work under prospective payment, thus reducing the demand for all types of personnel. Nursing homes and home care agencies would increase their demands for occupational therapists, but these increases would not offset the drop in demand from the hospital sector. Independent practice would thrive, however, as consumers sought services that were no longer available from institutions striving to reduce costs. Scenario 3: Access The general surge in demand for medical care generated by a policy of increased access to care would stimulate a demand for occupational ther

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 127 apists, providing rehabilitation services for newly entitled groups were incorporated into new benefit packages. Orthopedic problems that might have remained untreated for lack of funding would be cared for; in addition, the rehabilitation services needed after the acute phase of trauma or stroke could be provided. Handicapped individuals would have good access to occupational therapy services beyond their school years. If such groups as homeless people also gained access to care and mental health coverage were expanded, the demand for occupational therapists would be increased. Supply of Occupational Therapists For the past decade the number of occupational therapy graduates has fluctuated from year to year but has averaged around 2,000 for the last 2 years. After several years of stagnation in the 1080s the number of accredited programs recently jumped from 56 in 1985 to 63 in 1986 (CAHEA, 1987a). This surge appears to have outstripped the availability of full-time faculty, forcing programs to rely increasingly on part-time faculty (American Occupational Therapy Association, 1985). Furthermore, fieldwork placement of students is becoming more difficult. Educational programs reported that 424 facilities canceled placements in 1984-1985. This figure rose to 625 in 1985-1986. The most frequently cited reason for cancellation was the loss of occupational therapy staff (American Occupational Therapy Association, Research Information and Evaluation Division, 1986a). The committee heard persistent reports of employers' difficulties in recruiting occupational therapists, especially for rehabilitation facilities. These reports are substantiated by the few employer surveys that exist (Veterans Administration, Office of Personnel and Labor Relations, 1987; North Carolina Area Health Education Centers Program, 1987c). Also supporting the notion that occupational therapists are in short supply is the finding of a survey that starting salaries of occupational therapists in hospitals increased 31 percent between 1981 and 1986. This increase is comparable to those for pharmacists (30 percent) and staff nurses (27 percent), who are generally felt to be in short supply (University of Texas Medical Branch, 1981, 1986). These indicators of a tight labor market appear in the health care sector. Whether employers in other sectors are also having trouble hiring occupational therapists is not known. Nor is it known whether better opportunities for employment outside the health care sector are the cause of the health care employer's hiring problems. Conclusion Assuming that through the year 2000 the education sector is unable to respond to an increased demand for occupational therapists because of

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 128 faculty shortages, the committee expects to see health care employers making some adjustments that use the existing labor force more effectively and that encourage extended tenure and return to the labor force. Such adjustments are likely to include improvements in productivity, eliminating the use of occupational therapy in ways that have the least effect on patient care, and raising salaries. If faculty can be recruited to allow educational programs to expand, employers will have to make adjustments to attract people into careers in occupational therapy. Thus, to maintain a balance in demand and supply will take both salary and working condition improvements to bring in students, as well as expanded educational capacity to prepare the students for the workplace. If for some reason (e.g., health care facilities being unable to afford salary increases) the market fails to adjust sufficiently, a shortage of occupational therapists is likely. PHYSICAL THERAPISTS AND ASSISTANTS Demand for Physical Therapists and Assistants BLS expects the growth in the number of jobs available to physical therapists to exceed growth in all other allied health occupations. Between 1986 and the year 2000, 53,500 new jobs are predicted, representing an increase of more than 87 percent from 61,200 jobs to 114,700 jobs. This prediction is based on an expectation of rapid growth in several settings. In the hospital the push to shorter stays is expected to increase the demand for therapists, as is the move to home care. In addition, the attractions of independent practice are expected to continue to draw therapists. Although all of the major settings in which physical therapists work are expected to experience substantial increases in demand, it is notable that employment in ''offices of other health practitioners'' (that is, the offices of health practitioners other than physicians and dentists) will grow nearly threefold (adding over 25,000 jobs). Such offices will become the major employment setting for physical therapists, constituting almost 35 percent of all jobs. By contrast, hospital employment will grow about 43 percent, adding 8,500 jobs, but by the year 2000 will provide only 27 percent of jobs compared with the 35.5 percent share it had in 1986 (Table 4-7). Nevertheless, some of the therapists working in the "offices of other health practitioners" will be supplying services to hospitals and other health care facilities on a contractual basis. BLS expects the demand for physical therapy assistants to increase by 82 percent between 1986 and the year 2000, rising to 65,000 jobs. The similarity of the rate of growth for this group of practitioners to the predicted growth rate for physical therapists is due to the BLS analysts' de

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 129 termination that the same factors drive demand for the two groups. Payers can have a significant effect, however, on the use of assistant-level practitioners. Comments made during the committee's site visits to hospital physical therapy departments mentioned that limited use was made of assistants because of Medicare requirements that physical therapists perform the regular evaluations needed to document patient progress. These requirements were felt to limit the usefulness of assistants, resulting in their curtailed employment. Physical therapists themselves have often been reluctant to use assistants. TABLE 4-7 Major Places of Wage and Salary Employment for Physical Therapists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 61,200 114,700 employmentb Total wage and 56,200 100.0 105,400 100.0 salary employment Hospitals, public 19,900 35.5 28,400 26.9 and private Offices of 3,300 5.8 4,900 4.6 physicians Offices of other 11,500 20.4 36,600 34.7 health care practitionersc Outpatient care 3,000 5.3 6,500 6.2 facilities a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. These figures include 5,000 self-employed workers in 1986 and 9,300 in the year 2000 who are not allocated by place of employment. c Offices of health practitioners other than physicians (including osteopaths) and dentists. The figures also include offices of physical therapists. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. There is substantial support for the assumptions made by BLS about the growth in demand for physical therapists. Unlike the level of hospital employment of most other allied health occupations, hospital employment of physical therapists was not reduced in the years immediately following the introduction of PPS. Rather, physical therapist employment continued to grow by 5.3 percent between 1983 and 1985 (Bureau of Health Professions, 1985; American Hospital Association, 1987). Other evidence supports the idea that PPS has not reduced the use of physical therapy in hospitals. A study of seven acute care hospitals in one county indicated that referrals of Medicare patients to both inpatient and outpatient physical therapy increased after the introduction of DRGs. The implication to be drawn from this study is that physical therapy is seen as an effective and efficient treatment that can help to rehabilitate patients within time and economic constraints (Dore, 1987). Hospital employment is also being sus

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 130 tained by the expansion of hospital rehabilitation facilities and by the increasing intensity of care needed by inpatients. Because rehabilitation facilities are excluded from PPS requirements, these units are used to facilitate discharges from the PPS environment of the hospital. The American Physical Therapy Association (1987c) reported that therapists in home health care increased their hours of service and that demand for services in nursing homes increased. In 1983 there were approximately 1,700 physical therapists employed by Medicare-certified home health care agencies. An additional 2,155 provided contract services in the home. By 1985 the number of therapists employed in such agencies had increased to 6,685; employment dropped only slightly—to 6,234—in 1986 (American Health Care Association, 1987). The movement of patients out of the hospital to home health care, nursing homes, and rehabilitation facilities represents a change in the location of services rather than an increase in employment. Yet some factors are generating an increase in physical therapist employment in all settings. One such factor is physicians' and the public's perceptions of the need for physical therapy. Practitioners note that physician perception of the value of physical therapy services remains favorable, thus sustaining the level of referrals; at the same time, patient demand for therapy, especially for sports-related injuries, is at an all-time high. This latter reason is one of the factors that enables physical therapists to practice independently. According to a survey by the American Physical Therapy Association, between 1978 and 1983 the number of self-employed physical therapists increased from 10 percent to 14.6 percent of full-time physical therapists. Since 1983, however, this proportion has increased only to 15.8 percent. Part-time self employment shows a similar pattern, growing from 4.3 to 6.6 percent of employment between 1978 and 1983 and representing 7.7 percent of employment in 1987 (American Physical Therapy Association, 1987a). Whether this reduced growth is the result of a lack of growth in the demand for independent practitioner services or a lack of interest in that form of practice is not known. What is equally likely is that the rate of growth in independent practice will pick up again. Moreover, these self-employment figures do not represent the whole picture of independent practice in the field. Some physical therapists work for the proprietors of independent practices, for example. In 1987, 24.2 percent of respondents to the American Physical Therapy Association's survey said that they worked in a private physical therapy office. This figure probably includes the 17.9 percent who said they were owners, partners, or president of a practice or business (American Physical Therapy Association, 1987a). Whereas some therapists in private practice have contracted to supply hospital services, others have thriving practices to which physicians refer patients or, in some states, patients refer themselves. Thus, therapists are able to benefit directly from the public's favorable perception of the value

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 131 of their services. Committee site visits showed that, even in managed care systems in which utilization can be controlled, managers note that patient demand for physical therapy is pushing them to expand services—and in a competitive environment, managers are responsive to patient demand. Last but not least as a factor generating growth in the demand for physical therapists is the aging of the population. Elderly people need a greater volume and intensity of services to treat their multiple problems. Sixty-seven percent of physical therapists report that patients 64 and older are part of their patient population on a typical day (American Physical Therapy Association, 1987a). The demand for services from this important sector can only increase. Some care of the increasing number of elderly patients will take place in their homes. The lower productivity of physical therapists who must travel to their clients, as opposed to providing services in health care facilities, will further stimulate the demand for practitioners. The current relative availability of financing for physical therapy services should allow these changes to translate into a sharply increased demand for therapists. Insurers and employers have recognized the role of physical therapy in enabling people to return to work or in preventing institutionalization in expensive settings. Consequently, commercial insurers often cover the service. Workmen's Compensation programs cover much of the expense for testing and therapeutic treatments by physical therapists. Increased sensitivity to long-term costs has stimulated employers to cover the rehabilitation of workers and to pay for injury prevention programs in the workplace. Medicare covers home visits by physical therapists and physical therapy services in inpatient and outpatient settings and has not yet placed rehabilitation facilities under any kind of prospective payment restrictions. In sum, a combination of many factors should generate strong increases in the demand for physical therapists. The only foreseeable major change is the introduction by Medicare of a system of payment for rehabilitation services that contains an incentive to economize or ration services. If the past pattern of hospital staffing in response to DRG recurs, however, even this incentive may not reduce the demand for physical therapy services. Trends that are important to the future of demand for physical therapists and that should be monitored include the following: • growth of hospital care; • physician and public valuation of services; • changes in rehabilitation reimbursement; and • perceptions of the effectiveness of physical therapy in facilitating early discharge from hospitals and an early return to work and in preventing injury in the workplace. The major role of financing in generating a demand for physical therapists is reflected in the response of such demand to the three scenarios

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 132 described in Chapter 3. A downturn in demand is not foreseen in any scenario. Scenario 1: The Mixed Model With a continuation of the several financing systems that currently exist side by side, the demand for physical therapists would be high. Under this scenario, commercial insurers would pay independent practitioners and allow them to serve patients who increasingly want care for sports injuries, lower back pain, and other diagnoses that are treatable on an outpatient basis. Hospital use of physical therapists is stimulated by the admission of older, sicker patients who need services and by facilitating earlier discharges of other patients. Outpatient use also increases as financing continues to be available in all settings. One factor dampening demand, however, is an increasing effort on the part of the Health Care Financing Administration and other third parties to devise more stringent reimbursement screens as a way to constrain the growing utilization of services. Scenario 2: Prospective Payment With prospective payment the predominant form of financing, the demand for physical therapists would be somewhat lower than under the mixed payment model. Therapists in independent practice would feel the impact of lower demand as they were forced either to join a managed care system or to rely on patients' willingness to pay for services out-of-pocket. With emphasis on case management, utilization control, and cost-effectiveness the rate of growth in demand for therapy services would be reduced as physicians and case managers became more selective. Proved effectiveness would become increasingly important, and, until a body of research became available to prove effectiveness, the demand for some therapeutic modalities would fall. Scenario 3: Access The demand for physical therapists' services would receive added impetus if access to care were increased. Under this scenario, nonacute problems that went untended (e.g., back pain, muscle strain, arthritis, and osteoporosis) and preventive services that were not used in the absence of reimbursement would bring newly financed patients into the medical care system. The diminished need to cross-subsidize services for indigent patients would relieve some of the financial pressures on hospitals, which in turn would allow a lessening of productivity pressures and greater responsiveness to patients' demand for physical therapists.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 133 Supply of Physical Therapists Graduations from accredited baccalaureate, master's degree, and certificate programs in physical therapy increased by 43 percent between 1979-1980 and 1984-1985 to reach 3,499 in 1985. The increase in that year, however, was only 2 percent (American Physical Therapy Association, personal communication, 1987). This reduced rate of growth should not be interpreted as evidence of a drop in student interest. On the contrary: one dean described physical therapy programs as the "hottest spot on campus." A study conducted for the Health Resources and Services Administration shows that there is pressure on programs to expand their number of students. However, the difficulty of finding clinical sites for training may be slowing expansion (Mathematica Policy Research, Inc., 1987). Although competition for therapists is encouraging hospitals to continue or start training affiliations to ease their recruitment problems, they are also concerned about the costs of training, preferring more advanced students who require less supervision and are more productive. Partly because hospitals are reluctant to provide training and partly to introduce students to the practice sites in which they are likely to be employed, more non-hospital settings are being used for clinical training (Mathematica Policy Research, Inc., 1987). In the future, the constraints on growth in the supply of physical therapists are more likely to arise from problems in finding qualified faculty and training sites than from a lack of student demand. Currently, facilities are finding it difficult to hire physical therapists. For the whole period of the study the committee heard more reports of pressure in the labor market for physical therapists than for any other allied health group. Often, it appears that hospital recruitment difficulties are due to the inability of institutions to compete with the earnings available to therapists in other settings or in private practice. A solution is sometimes found in contracting for physical therapy services. In these cases, there is no "shortage," in the sense of therapists not being available at a price the facility is willing to pay, but rather "stress," in the sense of facilities having to alter their way of operating to accommodate the changing market. The sense of acute shortage reported to the committee from many sources (including representatives of national organizations, which suggests that this was not merely a local phenomenon) is supported by some admittedly limited evidence. Statewide surveys of North Carolina health care facilities reported that the vacancy rate for staff physical therapists almost doubled from 13.8 percent in 1981 to 26.9 percent in 1986. Vacancies for assistants more than doubled from 8 percent to 20 percent (North Carolina Area Health Education Centers Program, 1987a). These 1986 vacancy rates were higher than the rate for five of the six other allied health fields that were surveyed. Only occupational therapy had a higher vacancy rate at 25.1

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 134 percent in 1986 (North Carolina Area Health Education Centers Program, 1987a). Conclusion If the educational system continues to produce physical therapists at the current rate and the labor force behavior of therapists does not change, some major adjustments must occur to prevent a shortage of physical therapists from now until the year 2000. Shortages affect the various parts of the health care system differently. Sectors that pay workers more or have more attractive working conditions are likely to feel less of an impact. Sectors that are unable to hire a sufficient number of therapists because they cannot outbid the higher payers will be forced to reduce services. These reductions could create an access problem for some patients—probably those in need of long-term rehabilitation services and elderly people. The necessary market adjustments are likely to be made by both the education and employment sectors, with employers leading the way because they are the first to feel the effects of tight labor markets. Because student interest in a physical therapy career is already greater than current educational capacity can accommodate, salary increases will not be the most effective way of bringing new people into physical therapy. However, more pay should be effective in drawing back into the labor force those who have left and in encouraging practitioners to remain active. Salaries are likely to increase, and hospitals and other employers are expected to seek more productive and effective ways of employing therapists, thus somewhat reducing demand. Extended tenure in the labor market should contribute to the needed adjustment. As salaries rise, and if independent practice and professional growth opportunities increase, practitioners can be expected to remain in the labor force longer and return more readily after leaving. Changes of this sort make major contributions to relieving labor market stresses. Employers who are concerned about enhancing the supply of physical therapists should begin to understand that the costs of participating in the clinical component of education programs will outweigh the costs of adjusting to both lower levels of physical therapy use and the major salary increases needed to attract therapists. If this and other adjustments occur, graduations will eventually increase, and, as the supply of new therapists responds to demand, the rate of salary increases will abate and a balance between demand and supply will be found. If, as some desire, a master's degree becomes the entry-level requirement for the field, the supply of new practitioners would be more constrained. Whether raising the entry-level degree would also increase salaries and reduce the demand for therapists is a matter of contention. Some say that

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 135 higher levels of professional training require greater compensation for the greater educational investment and are thereby linked to higher costs of care— and in times of cost containment, to smaller amounts of care (Havinghurst, 1987). Yet the American Physical Therapy Association believes this argument is wrong for several reasons: more educated practitioners are more likely to work independently with fees that are no higher than the charges assessed by institutions that employ therapists—and even if therapists were more highly paid, the cost of a $3,000 salary increase to full-time, salaried physical therapists in hospitals would represent less than half of 1 percent of the average annual increase in hospital care expenditures (American Physical Therapy Association, 1987b). RADIOLOGIC TECHNOLOGISTS AND TECHNICIANS Demand for Radiologic Technologists and Technicians BLS estimates that between 1986 and the year 2000 the number of jobs for radiologic technologists and technicians will grow by 65 percent, from 115,400 to 190,100. This high rate of growth is similar to that expected for dental hygienists, and it exceeds the expected job growth rates for dietitians, speech- language pathologists and audiologists, and occupational therapists. Jobs for nuclear medicine technologists, who are excluded from the BLS definition of radiologic technologists and technicians, are expected to increase by nearly 23 percent, from 9,700 to 11,900. To prepare their estimates, BLS analysts evaluate job opportunities in the many different areas radiology encompasses including sonography, fluoroscopy, mammography, computerized tomography, magnetic resonance imaging (MRI), and radiation therapy. Two of the more specialized fields with distinct accreditation for educational programs include radiation therapy and sonography. In addition to analyzing the prospects for each speciality, BLS analyzes the growth in the number of jobs in different settings—predicting increasing employment opportunities in nonhospital settings such as HMOs, imaging centers, and physician offices (in which 27.4 percent of all radiologic technologists and technicians were employed in 1986 and almost 38 percent are expected to be employed in the year 2000). Today, hospitals are the major employers of radiologic technologists and technicians, supplying a little more than 60 percent of all available jobs (Table 4-8). BLS predicts that by the year 2000, however, only 48 percent of jobs will be in hospitals. This reduction does not mean that the number of hospital jobs will fall—only that the rate of increase in hospitals will be below the rate of job growth in other settings. Indeed, BLS expects the number of hospital jobs to increase by 21,400—from 70,200 in 1986 to

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 136 91,600 in the year 2000. A similar pattern is predicted for nuclear medicine technologists (Table 4-9). The change of inpatient radiology departments from revenue centers to cost centers that has occurred under PPS and the increased use of utilization review were expected to result in the reduced use of ancillary services, especially diagnostic imaging (Steinberg, 1985). TABLE 4-8 Major Places of Wage and Salary Employment for Radiologic Technologists and Technicians, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 115,400 190,100 employmentb Total wage and 114,400 100.0 188,200 100.0 salary employment Hospitals, public 70,200 61.4 91,600 48.7 and private Outpatient care 2,500 2.2 9,400 5.0 facilities Offices of 31,300 27.4 71,000 37.7 physicians Offices of dentists 1,200 1.0 1,900 1.0 Offices of other 1,500 1.3 4,000 2.1 health care practitioners a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. These figures include 1,000 self-employed workers in 1986 and 1,900 in the year 2000 who are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative. TABLE 4-9 Major Places of Wage and Salary Employment for Nuclear Medicine Technologists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 9,700 11,900 employmentb Total wage and 9,700 100.0 11,900 100.0 salary employment Hospitals, public 8,600 88.6 10,000 83.9 and private Medical and 500 5.2 700 6.1 dental labs Offices of 400 4.1 800 6.6 physicians a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. Self-employed persons are not allocated by place of employment. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 137 Pre-and post-PPS employment patterns in hospitals appear to offer equivocal support for this notion. According to American Hospital Association data, x-ray technologist, radiation therapy technologist, and nuclear medicine technologist employment declined between 1983-1985, compared with 1981-1983, when employment had risen or been close to stable. For other radiologic personnel, employment had been falling before PPS, but the rate slowed after its introduction (Bureau of Health Professions, 1985; American Hospital Association, 1987). It is difficult to ascertain exactly what changes are occurring. In a 1985 survey of nuclear medicine department directors, administrators, or chief technologists, 20 percent of the respondents reported a decline in the number of employed nuclear medicine technologists, 65 percent reported a decrease in inpatient volume, and 58 percent reported an increase in outpatient volume. These data were interpreted as the product of lowered admissions, of physicians ordering fewer tests, and of the shifting of routine testing to the outpatient setting (Crucitti and Pappas, 1986). A more widely based 1985 survey of hospital radiology by the American Hospital Radiology Administrators (Conway, 1985) asked whether volume had increased, decreased, or remained stable in 33 procedures. More than 40 percent of the respondents reported decreases in three types of procedures including skull and gastrointestinal imaging. By contrast, more than 40 percent of the respondents reported increases in 17 procedures including various fluoroscopy studies, cardiac catheterization, cardiac ultrasound, various computerized tomography (CT) studies, and radiotherapy treatments. The overall findings echoed those of the nuclear medicine survey: 66 percent of the respondents reported a decrease in inpatient workload and 44 and 57 percent of the respondents reported increases in outpatient clinic and private workloads, respectively. Radiology services appear to reflect a generally observed pattern of post- PPS utilization: services declined dramatically in the 2 years after PPS was introduced and turned up again in 1985 and 1986. Factors that limit further staffing reductions include the increased severity of illness among patients, reduced opportunities to shift the patient to an outpatient setting, and fewer chances to cut unnecessary services (Prospective Payment Assessment Commission, 1987). Looking to the future, the aging population and its need for more intensive care, together with the existing upward trends in radiologic usage, point to continued increases in the demand for radiologic personnel. The types of personnel likely to be in demand in the future depend to some extent on technological changes; however, it is difficult to estimate the impact and rate of such changes. The emergence of new imaging modalities such as MRI and positron emission tomography or, going back

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 138 to the 1970s, the new application of computer technology to imaging has generated major improvements in diagnostic capabilities. The new technologies have not always supplanted the old; rather, the new imaging procedures are often used after more customary work is inconclusive. In addition, the new imaging technologies are labor intensive. Scanning procedures are more time- consuming than film x rays. Whether the rate of diffusion of future new imaging modalities will be as great as in the past is an open question. Payers have an interest in controlling the spread of expensive innovations. (Many will remember the attempts that were made to limit the number of CT machines through certificate-of-need reviews.) Today, facilities are more reluctant to buy expensive equipment unless it is believed to be cost-effective or represents a significant improvement in patient care. Employment outside the hospital is expected to be an increasing source of demand for radiologic technicians and technologists. Freestanding imaging centers, started by physicians to develop a ''niche'' in the health care market, are already seen as luring technologists away from hospitals. HMOs and group practices are providing onsite radiology; physicians increasingly have x-ray capability in their offices. In some states, unlicensed personnel may operate x- ray equipment in low-volume settings; in others, however, only licensed personnel may do so. Indeed, licensing provisions will be a significant force influencing the demand for radiologic personnel. For example, in some states, ambulatory care centers that hire personnel to carry out two functions must hire licensed x-ray technicians rather than laboratory technicians to provide both x- ray and lab services because the provision of x-ray services requires a licensed technician to operate the equipment. A committee site visit to Boston revealed that newly enacted licensing laws generated a sharp spurt in demand for technicians when licensed personnel had to be hired to replace unlicensed staff. As a result, even an employer who was willing to offer substantially increased pay was unable to attract job applicants. Another force that could sustain a high level of demand for radiologic personnel is public knowledge about and valuation of x-ray procedures. The media's attention to imaging has developed public consciousness; this, together with physicians' appreciation of the available diagnostic capabilities, should ensure that demand is sustained. Thus, demographic trends, technological trends in hospital care as well as in outpatient care, and other forces will combine to sustain a high level of demand for radiologic occupations. The BLS' estimated 65 percent increase in jobs up to the year 2000 seems reasonable. Those interested in tracking the future demand for radiologic technicians and technologists should monitor the following factors:

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 139 • hospital utilization, especially intensity of care and case mix; • growth of all types of freestanding facilities; • licensure changes; • technological changes that are likely to cause new areas of specialization; and • results of technology assessment. Although recent financing changes have had less effect on the radiology field than some had expected, the financing changes envisioned in the three scenarios described in Chapter 3 could have a marked effect. Scenario 1: The Mixed Model Under this scenario, overall growth in the health care sector, faster growth in outpatient care, and public and physician appreciation of diagnostic imaging would combine to generate prolonged growth in the demand for radiologic technicians and technologists. Scenario 2: Prospective Payment The rate of growth in the demand for radiologic technicians and technologists in hospitals would slow as admissions fell even though the intensity of care increased for an older, sicker patient population. The use of imaging as an aid to speedy diagnosis and discharge would be encouraged. Radiologic technologist and technician demand from outpatient settings would increase, both from a transfer of procedures out of the hospital setting and from an increase in freestanding facilities. In all settings, productivity pressures would also squeeze demand. Competitive pressures would force managers of managed care systems to seek the most productive sites for radiologic referral. Hospitals and imaging centers would limit staff to price services competitively. Scenario 3: Access Because imaging of one sort or another is used in almost all types of health care—primary through tertiary—and by many medical specialities, the increased use of health services that would result from a policy to improve access would inevitably produce the increased utilization of radiology services. Even if such a policy were accompanied by utilization controls, such as case management, it is difficult to believe that anything other than a major increase in demand for radiologic personnel would occur under this scenario.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 140 Supply of Radiologic Technologists and Technicians In a trend that accompanies a long-term shift from hospital-based to college-based programs, the number of radiography education programs has decreased 23 percent between 1976 and 1986. For several years the changing location of educational programs did not affect the number of graduates substantially. But a sudden decline in graduations of about 15 percent has occurred recently—from 7,393 in 1985 to 6,400 in 1986 (CAHEA, 1987a). This decline may be the result of potential students responding to fears of reduced demand that have been generated by prospective payment. Two smaller and nearer radiologic specialities—nuclear medical technology and radiation therapy technology—each show a different pattern. After rapid growth in the 1970s, nuclear medical technology experienced a 25 percent decline in graduations between 1984 and 1986. By way of contrast, radiation therapy technology graduations show slow but sustained growth over the past 2 decades (CAHEA, 1987a). There are indications that radiologic technologists, especially those with specialized training, are finding jobs easily. Hospitals are competing with freestanding employers for scarce personnel (Mathematica Policy Research, Inc., 1987), and the committee's site visits found some employers who were unable to hire the staff they were seeking. Other data suggest that, if employers are having a hard time hiring radiologic staff, this may be a phenomenon of quite recent occurrence. A 1986 survey of health care facilities in North Carolina reported that at 8 percent the overall vacancy rate for radiologic personnel was very low compared to other allied health fields—for example, 11.9 percent for medical record administrators and 17.9 percent for respiratory care personnel (North Carolina Area Health Education Centers Program, 1987d). Finally, adding to the impression of a field in which employers are starting to have difficulties in hiring staff is the result of a survey of education program directors. The percentage who believe that radiography is an attractive opportunity increased from 60 percent in 1981 to 89 percent in 1987 (Parks and Hedrick, 1987). Conclusion Even if the decline in graduations from radiologic education programs is halted, strong adjustments in the labor market will be needed to avoid a shortage of practitioners through the year 2000. Salary adjustments are the key in any strategy designed to alleviate labor market stresses. Salary increases can attract new entrants to the field, encourage the return of those who have left, and prolong the attachment to the field of those already in it. Future supply is highly sensitive to even small increments in any or

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 141 all of these variables. The committee believes that early and significant action in this field is needed to forestall serious problems in the future delivery of health care services. Focusing on salary increases could be particularly productive in this field. Although starting salaries are competitive, later, radiologic technicians are less well compensated than, for example, computer programmers and operators and engineering technicians—occupations that may be competing for the same students (University of Texas Medical Branch, 1986). Education program directors more often believe that radiographic graduates are more inappropriately compensated than other comparable allied health graduates, except those who work in laboratories (Parks and Hedrick, 1987). Health care providers play a particularly important role in generating an adequate supply of radiologic personnel. Many education programs are hospital based, and all are heavily dependent on health care facilities to open clinical training opportunities to students. Because of the expense of equipment and the impossibility of simulating patient contact, academic institutions must maintain close ties with clinical sites. Despite such costs as decreased productivity, increases in repeat tests, and faculty salaries, health care providers should not underestimate the importance of offering clinical training opportunities to secure a continuous supply of personnel for themselves as well as for other providers. RESPIRATORY THERAPISTS Demand for Respiratory Therapists BLS predicts that by the year 2000 there will be 75,600 jobs for respiratory therapists—an increase of 34 percent from the 56,300 jobs available in 1986. This level of growth is substantially higher than will occur in total national employment (19 percent) and in some of the allied health occupations (e.g., clinical laboratory technologists or nuclear medicine technologists). Yet such growth appears moderate when compared with that predicted for physical therapist and medical record technician employment (in excess of 70 percent), and occupational therapist and radiologic technician and technologist employment (BLS expects growth in these jobs to the year 2000 to exceed 50 percent). The BLS estimate of 34 percent growth through the year 2000 is based largely on an assessment of how respiratory therapists will fare in the hospital setting, in which almost 88 percent were employed in 1986. Although BLS predicts only a 12.2 percent increase in overall hospital employment through the year 2000, its analysts expect hospital demand for respiratory therapists to increase by 95 percent because of the increased

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 142 admissions of older, sicker patients who require more intensive care. BLS also sees some demand for respiratory therapy being generated by improvements in trauma care that allow more accident victims in need of ventilator care to survive. The development of small ventilators for low-birth-weight neonates is a technological factor that will be instrumental in increasing the demand for respiratory services in hospitals. BLS foresees increasing specialization within the profession as therapists become more expert in such areas as neonatal and cardiac care. Simultaneously, BLS expects that respiratory therapists will expand their range of skills, moving into such areas as electrocardiography (EKG). This competency in particular would allow hospitals to curtail the EKG staff employment for 24 hours per day by using respiratory therapists who were already there. Thus, BLS analysts expect that nearly 82 percent of the projected 75,600 respiratory therapist jobs will be in hospitals in the year 2000 (Table 4-10). The outlook for increased employment of respiratory therapists in home health agencies is not viewed optimistically by BLS analysts who expect reimbursement policies to prevent any significant expansion of home care opportunities for respiratory therapists. TABLE 4-10 Major Places of. Wage and Salary Employment for Respiratory Therapists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 56,300 75,600 employmentb Total wage and 56,300 100.0 75,000 100.0 salary employment Hospitals. public 49,400 87.7 61,900 81.8 and private Outpatient care 700 1.2 1,500 2.0 facilities Offices of 500 0.9 1,100 1.5 physicians Offices of other 2.000 3.5 3,300 4.3 health care practitionersc Other health and 3,400 6.1 7,300 9.7 allied health care facilitiesd a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. Self-employed persons are not allocated by place of employment. c Offices of health practitioners other than physicians (including osteopaths) and dentists. d Health care facilities other than the offices of physicians, dentists, and other health care practitioners; nursing and other personal care facilities; hospitals; medical and dental laboratories; and outpatient facilities. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 143 In the current political and financing climate, Medicare reimbursement policies for respiratory therapy in the home support the BLS notion that, by and large, future employment will be generated mainly in hospitals. The services of respiratory therapists are not reimbursable by Medicare on a per-visit basis; rather, the costs must be included in administrative expenses. Thus, employment by home health agencies is low; more often, respiratory therapists are retained as consultants to staff who make home visits. Of 214 home health agencies surveyed, only 12 employed a respiratory therapist either as a staff member or as a contracted consultant (Health Care Financing Administration, 1986b). A recent report to Congress answered in the negative the question of whether Medicare coverage should be expanded to include respiratory therapist visits. The report noted that nurses, who are covered on a per-visit basis, can treat many patients who are in need of respiratory care and can be specially trained, if necessary. Little evidence was found to show that hospital stays would be reduced by expanded payment for home care services, and although many Medicare beneficiaries can be helped by respiratory care, the existing levels of service were deemed sufficient (Health Care Financing Administration, 1986b). Respiratory equipment and supplies for use at home are covered by Medicare under the durable medical equipment benefit. Equipment supply companies support home patients by hiring professional staff (e.g., respiratory therapists) who can supervise the installation of equipment and undertake patient education. (However, the American Association of Respiratory Care reportedly has had difficulty in tracking employment in durable medical equipment companies.) Despite perceptions that increasing numbers of patients could benefit from respiratory therapy services in their homes (see, for example, Gilmartin and Make, 1986), respiratory therapists are unlikely to experience significant increases in home care work unless reimbursement policies change. A 1986 study by the American Association for Respiratory Care provides tentative support for the BLS view that respiratory therapy employment in hospitals has the potential to grow at a faster rate than overall hospital employment, once productivity gains have reached their limits. The association surveyed hospitals and educators to evaluate the impact of PPS. It found that since 1983 hours of respiratory care services increased in more than half of the surveyed hospitals, and admissions of patients with respiratory-related diagnoses stayed the same or increased in 70 percent of the hospitals. However, in respiratory therapy departments the personnel budgets and level of employment were generally either stable or decreased (American Association for Respiratory Care, 1986b) suggesting that improvements in productivity had occurred. Other changes that are occurring within hospitals can generate continued steady employment growth for respiratory therapists. As suggested by BLS,

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 144 respiratory therapists are increasingly being used to provide non-respiratory care services (American Association for Respiratory Care, 1986a). In one hospital visited by the committee, respiratory therapists reported that they had expanded into cardiopulmonary areas such as the cardiac catheterization laboratory, increased their activity in hemodynamic monitoring, and were "filling in" to provide electroencephalography (EEG) and EKG services. The aging population is also likely to increase patient admissions with cardiopulmonary disease and dysfunction. Chronic obstructive pulmonary disease and lung cancer exemplify diseases to which elderly people are particularly prone. Countering these upward movements in demand are downward pressures that could occur if researchers and managers look more critically at services. A 1986 editorial in the New England Journal of Medicine (Petty, 1986) noted that, in the shift to PPS, respiratory therapy was targeted "as a likely example of undisciplined practices and excesses for reasons that included a dearth of good scientific data on many techniques in common use." Noting studies that showed evidence of the effectiveness of some therapies, as well as one study indicating that sometimes respiratory therapy can be reduced without affecting disease outcome, the editorial concluded with a call for an improved scientific data base to guide practice. The extent to which respiratory therapy staff are vulnerable to reductions in times of constraint will depend only in part on evidence of the necessity for or effectiveness of services. Other important factors include an absence of patient demand for therapy services and the strength of department managers in each hospital's hierarchy. It was noted on one site visit that, although the volume of respiratory therapy services has diminished outside of intensive care units (ICUs) because of more stringent utilization review and the improved use of medications, simultaneously, ICU activity has shown large increases with sicker patients needing ventilation care. In sum, the BLS analysis of moderate growth in jobs for respiratory therapists is well substantiated. Hospital employment is the chief source of growth, stimulated by the aging population and the demand generated by new technologies that save extremely sick individuals. Out-of-hospital employment is small and likely to remain so. Even a large increase in non-hospital demand would have only a small effect on total demand for respiratory therapists. Factors that will have an important effect on respiratory therapy employment include the following: • hospital admission rates; • severity of hospital admissions; • disease patterns, especially cardiopulmonary diseases; • the outcome of effectiveness studies;

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 145 • the expansion of activities of respiratory therapists into new areas; • Medicare reimbursement of respiratory therapists in home care; • employment by the durable medical equipment industry; and • expanded use in nursing homes. The last three factors can diminish the dependence of the profession on hospital employment. However, because an explosion of out-of-hospital employment is unlikely, growth in the number of jobs will probably continue at the moderate rate forecast by BLS. In addition to the above factors, which should be tracked to identify trends in demand for respiratory therapists, major financing changes, as outlined in the scenarios in Chapter 3, will also have major impacts. Scenario I: The Mixed Model Growth in hospital employment would continue to be moderate, fueled largely by the aging population. Employment in home care would increase only slightly as reimbursement constrains home visits. Because employment in other settings would continue to be minimal, hospital growth would overwhelm other changes. Scenario 2: Prospective Payment Under this scenario, the increased use of prospective payment would force hospital administrators to seek ways to reduce costs as hospital utilization fell. Respiratory therapy would probably be vulnerable unless it could be shown to contribute to early discharges. Hospitals would also seek to increase their stake in nonhospital markets to ensure that, after earlier discharge, patients' continuing care produced revenue for the hospital. Hospitals would become purveyors of more intensive home care, including respiratory therapy in modest amounts. Employment by durable medical equipment companies would increase as they provided more intensive out-of-hospital services. However, if it should occur, the contraction of employment in the hospital sector would overwhelm all other effects. Scenario 3: Access The greatest increase in demand for respiratory therapists would occur with this scenario. Hospital use would be stimulated by making financing available to people who today are unable to obtain hospital care. Yet some of the hospital expansion would occur in elective procedures that today are postponed for lack of financing until sickness is acute. These less acutely sick patients are less intense users of respiratory therapy services than are sicker patients, however.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 146 Supply of Respiratory Therapists The characteristics of today's respiratory therapy work force reflect the multiple routes of entry into the field that have existed until now but that are fast disappearing. Analyses of the 1980 census indicated that a significant proportion of the work force, including credentialed personnel, had only on-the- job training (Health Resources and Services Administration, 1984). Currently, there is a trend toward training in programs that culminate in certification or licensure or both. As a result the shorter programs that provide training for the lower level respiratory technicians are disappearing. The number of accredited technician programs has decreased by 2.3 percent, from 173 in 1980 to 169 in 1986. The number of graduates has decreased by 21 percent, from 3,206 in 1980 to 2,539 in 1986 (CAHEA, 1987a). Accompanying the move to certified personnel, sponsorship of educational programs has shifted from hospitals to colleges and universities. Community colleges now offer the greatest proportion (66 percent) of programs. The number of accredited therapist programs has increased by 34 percent, from 175 in 1980 to 235 in 1986. Yet the number of graduates has not shown parallel growth. Rather, it has fluctuated from year to year with a high of 3,868 in 1985 followed by a 6-year low of 2,740 in 1986 (CAHEA, 1987a). This fluctuation suggests that during years of low demand there is excess educational capacity. Furthermore, the trend in graduates bears watching to determine whether the 28 percent drop in graduates between 1985 and 1986 is other than an anomaly. The committee has heard conflicting reports of the availability of respiratory therapists, suggesting that there are substantial differences among local markets. Salary data are equivocal in their support of the notion that the labor market may be very tight. At least two data sets allow comparisons of the rate of salary increases among selected allied health professions: the Bureau of Labor Statistics' (1983-1986) Current Population Survey and the University of Texas's National Survey of Hospital and Medical School Salaries. In the Current Population Survey, the salaries of respiratory therapists showed the greatest rate of increase of the allied health professions under scrutiny. In the University of Texas's survey (University of Texas Medical Branch, 1981, 1986), the rate of salary increase for respiratory therapists fell in the bottom third when compared with rates of increase for 19 other groups of hospital employees (Bureau of Labor Statistics, 1983-1986). These data do not allow any firm conclusion about the present state of the market for respiratory therapists. Conclusion If the number of graduates from educational programs can be maintained at approximately today's level, the nation's supply of respiratory

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 147 therapists should be adequate to the demand for services through the year 2000. This statement implies that significant changes in the rate of salary growth or major improvements in the conditions of employment should not be expected. To maintain this balance, educational capacity and student interest must be sustained. The fluctuations in graduations suggest that students may need encouragement in the form of increased job attractiveness to keep up the necessary level of interest in the field. Some caveats about the committee's estimate of the balance between demand and supply are in order. In assessing future supply, the committee assumed that respiratory therapy work force behavior would be comparable to the work force behavior of members of other therapy fields. Unlike many allied health fields, men are a substantial proportion (about 40 percent) of the respiratory therapy labor force. The significance of this representation in terms of geographic mobility, labor force attachment, or responsiveness to economic incentives—as compared with fields in which almost all the workers are women —is not fully known. If it is true that men remain in the labor force longer than women, the committee's estimate of future supply may be conservative. In conclusion, until better information about the long-term labor force behavior of respiratory therapists is available, it is reasonable to believe that labor markets will make necessary adjustments smoothly to maintain a reasonable equilibrium between the demand for and supply of respiratory therapists. The volatility of the number of graduates, however, suggests the need for close monitoring of emerging educational trends. SPEECH-LANGUAGE PATHOLOGISTS AND AUDIOLOGISTS Demand for Speech-Language Pathologists and Audiologists The BLS predictions of an additional 15,500 jobs for speech-language pathologists and audiologists by the year 2000 represents an increase (by 34 percent) to a total of 60,600 jobs. BLS estimates that there were 45,100 jobs in 1986, including jobs in education that were in some cases filled by individuals with baccalaureates rather than the professional entry-level master's degree. The American Speech-Language-Hearing Association (ASHA) has estimated that 42,390 of its members—all of whom hold at least a master's degree—were in the active work force. Non-ASHA members in the active work force, including people with only a bachelor's degree, were estimated to number 41,000 (Shewan, 1987). Thus, the association estimates that there is a total of 83,000 people in speech-language and audiology jobs—a figure vastly larger than the BLS job estimate. The growth rate predicted by BLS through the year 2000 is similar to that predicted for occupational therapists and stems from a similar factor that is unusual among allied health practitioners—significant employment

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 148 outside the health care system. In 1986 only 28.6 percent of speech-language pathologist and audiologist jobs were in the health care services industry. Sixty- four percent were in educational services—a sector in which BLS expects demand to be close to stagnant (Table 4-11). Between 1986 and the year 2000, speech-language pathology and audiology jobs in the education sector are expected to increase by only 14 percent. ASHA notes that 13.6 percent of speech-language pathologists and audiologists report that they run their own practices or are independent contractors (American Speech-Language-Hearing Association, 1988). BLS analysts caution that their classification of speech-language pathologists and audiologists includes those prepared only to the bachelor's degree level. These practitioners are not certified by ASHA, which certifies at the master's degree level and above, and thus cannot work in the 36 states with licensure requirements. BLS analysts believe that most non-ASHA-certified personnel are employed in educational services by state education departments in states that certify individuals who have only a bachelor's degree or who lack other qualifications for ASHA certification. TABLE 4-11 Major Places of Wage and Salary Employment for Speech-Language Pathologists and Audiologists, 1986 Actual and Projected for the Year 2000 Employment Number of Percentagea Number of Percentagea Setting Jobs, 1986 Jobs, 2000 Total 45,100 60,600 employmentb Total wage and 42,100 100.0 56,500 100.0 salary employment Educational 27,000 64.0 30,800 54.62 institutions, public and private Hospitals, public 4,400 10.4 5,600 9.9 and private Outpatient care 2,700 6.4 4,400 7.7 facilities Nursing and 1,200 2.7 1,900 3.4 personal care facilities Offices of 1,800 3.6 2,900 5.2 physicians Offices of other 1,200 2.7 4,400 7.7 health care practitionersc a These percentages were calculated using unrounded figures and therefore will not be identical to percentages that are calculated using the rounded figures provided in the table. b Total employment = wage and salary employment + self-employment. These figures include 3,000 self-employed workers in 1986 and 4,096 in the year 2000 who are not allocated by place of employment. c Offices of health care practitioners other than physicians (including osteopaths) and dentists. The figures include offices of speech-language pathologists and audiologists. SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 149 There is considerable support for the BLS estimates. Although speech- language pathologists and audiologists may see new opportunities for employment growth under the 1986 Education of the Handicapped Act (which increased the demand for these professionals by funding programs for young children), total employment growth in the education sector will be relatively slow. New employment opportunities will occur in other settings, however. Speech-language pathologists and audiologists are well positioned to benefit from changes occurring in the health care system. Their lesser dependence on hospital employment (which accounted for only 10 percent of jobs in 1986) makes them less vulnerable to any squeeze on employment in that sector. Their reimbursement status positions them to benefit from shifts to care outside of hospitals. Under the Omnibus Budget Reconciliation Act of 1980, a speech- language pathologist may develop a plan of care for patients referred by a physician and be reimbursed by Medicare. Prior to 1980 the amount, duration, and scope of services had to be specified by the physician. Since 1986 speech- language pathology has been included among the therapies that together must be provided for a total of 3 hours per day for a beneficiary to be eligible for Medicare coverage in an inpatient rehabilitation facility. While this could provide an impetus to increased demand for speech-language pathologists, it could also be short-lived as Medicare seeks ways to find an equitable reimbursement system that includes cost-control incentives. Medicare will also reimburse for home care visits, a provision that positions therapists to care for the growing population of patients discharged from hospitals or in need of long- term home care (American Speech-Language-Hearing Association, 1987b). According to the Health Care Financing Administration the estimated number of speech-language pathologists employed by Medicare-certified home care agencies grew from 303 in 1983 to 5,503 in 1985; the figure dropped to 3,113 in 1986 (American Home Care Association, 1987). The extent to which this drop is due to increased contracting for services or other arrangements is not known. Approximately 48 percent of freestanding home health agencies offer speech-language and audiology services (American Speech-Language-Hearing Association, Task Force on Home Care, 1986). Although only a minority of speech-language pathologists and audiologists are employed in hospitals, their use in that setting has not been constrained by PPS. Indeed, between 1983 and 1985 their FTE employment in hospitals increased by 21 percent from 2,684 to 3,252. Committee site visits uncovered several possible reasons for this increase. One is expanded speech and hearing coverage by HMOs. Audiology personnel working in hospital outpatient areas are finding that HMO patients are covered for the full range of diagnostic testing and hearing aids. (Previously, commercial insurance subscribers were covered for only a narrow range

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 150 of hearing testing.) Speech-language pathologists also cited a growing demand for services for stroke and head-injured patients whose survival rates have improved with the advent of new knowledge and technology. Audiologists noted a growing incidence of hearing defects in young people who listen to music through headphones. Both occupations cited the growing numbers of elderly patients using their services plus an increasing understanding of their work by physicians that has resulted in more numerous referrals. In sum, speech-language pathologists and audiologists in their major employment setting—educational institutions—are not likely to experience rapid increases in demand. In health care settings, they are positioned for steady growth. Reimbursement allows them to take advantage of the shift to nonhospital care in many settings. Given the expected slow growth in education and faster growth in health care settings, the overall moderate growth predicted by BLS seems reasonable. Factors to be monitored by those wishing to track future demand for speech-language pathologists and audiologists include the following: • Medicare reimbursement of rehabilitation services; • school system growth and financing; • patterns of specific diseases and treatment such as stroke, head trauma, and deafness in youth; and • growth in independent practice opportunities and contractual arrangements with freestanding speech-language pathology and audiology organizations. The way in which the three scenarios described in Chapter 3 play out for speech-language pathology and audiology is largely determined by the pattern of employment across the various health care settings and outside the health care system. Scenario 1: The Mixed Model With this scenario, speech-language pathologists and audiologists would be in steady demand as their services were included in comprehensive HMO benefit packages and increasing numbers were needed to work in the less productive home care environment. The demand for rehabilitation and outpatient services would also show steady growth. Scenario 2: Prospective Payment Because only a small proportion of speech-language pathologists and audiologists work in hospitals, the impact of increased prospective payment in this setting would have little impact on total demand. Similarly, bringing

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 151 rehabilitation services under prospective payment would result in only a small reduction in overall demand. Outpatient care would show overall growth, but speech-language pathology and audiology would not benefit greatly because these services would be seen as less vital than others that related more directly to physical health. Less vital services would be most vulnerable to reduction under prospective payment. Combining the slight growth in outpatient demand with the reduction in inpatient demand would yield stagnant total demand from the health care sector under this scenario. Scenario 3: Access Speech and hearing deficits are among the group of health problems that are likely to go unserved if individuals experience financial barriers to health care. Under this scenario, those financial barriers would be lowered and previously ignored communicative deficits would receive attention, stimulating greater demand for speech and hearing services in inpatient and outpatient settings. Supply of Speech-Language Pathologists and Audiologists In 1986 304 programs offered degrees in communication sciences and disorders. Of these programs, 21 percent offered only undergraduate degrees. The total number of programs has been quite stable since 1983, ranging between 293 and 304 (Cooper et al., 1987). The number of bachelor's degrees awarded has declined since 1981 by 15 percent to 4,300. The decline was confined to only 2 years, however. The latest figures show an upturn (CAHEA, 1987a). The picture for master's degrees is a little clearer: the number of degrees awarded since 1982 has remained relatively stable. Yet this trend must be viewed together with that for bachelor's degree graduates (Cooper et al., 1987). Approximately 90 percent of master's degree graduates in speech pathology and audiology have undergraduate degrees in the same disciplines. Furthermore, the number of master's degree graduates closely matches the undergraduate degrees in speech and audiology—with a 2-year time lag (Cooper et al., 1987). It seems reasonable to conclude that most speech-language pathology or audiology undergraduates move on to a speech-language pathology or audiology master's degree and that bachelor's degree graduates are the pool from which therapists are drawn. Consequently, we must consider undergraduate as well as graduate degrees as an indicator of future supply. The committee is not aware of any evidence that demand and supply are not currently in balance in this field. Although committee members

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 152 occasionally heard that rehabilitation facilities were experiencing difficulties in filling vacancies for speech-language pathologists, they also heard that some independent practitioners were unable to generate enough business and were returning to employment in other facilities. Such comments were rare, however, and do not disturb the overall picture of an adequate current supply of practitioners. A national survey of starting salaries for speech-language pathologists in hospitals shows an increase of 23 percent between 1981 and 1986. This increase was lower than that for 17 of 19 other types of personnel. The 33 percent increase for audiologists, however, was higher than that of pharmacists and nurses who are thought to be in short supply (University of Texas Medical Branch, 1981, 1986). These data indicate a difference in demand for the two types of practitioners but are not in themselves sufficient evidence on which to base a judgment of the markets. Conclusion If baccalaureate graduations remain at approximately the level of the last few years and if most of these graduates go on to master's degrees in speech- language pathology or audiology, there should be a continued balance between demand and supply through the year 2000. This statement implies that significant changes in the rate of salary growth or major improvements in the conditions of employment should not be expected. However, the production of baccalaureate graduates should be carefully monitored. The data to this time do not indicate whether a downward trend is beginning to develop. If a decline does occur, employers who feel the impact of the drop will need such factors as higher salaries to influence people to pursue careers in language and hearing disorders. CONCLUSION This chapter applies the best available data to assess how the forces that drive the demand for and supply of allied health personnel will affect allied health labor markets. The committee's intention is to alert decision makers to the kinds and magnitudes of market adjustments that they should expect and encourage to sustain a long-term balance between allied health personnel demand and supply. For some fields (e.g., physical therapy, radiologic technology, medical record technology and administration, and occupational therapy), we foresee a need for decision makers to use the mechanisms under their control to improve the working of the market so that severe imbalances in demand and supply may be prevented. Employers are already concerned about difficulties in hiring in some of these fields, and there are signs that health

DEMAND AND SUPPLY IN 10 ALLIED HEALTH FIELDS 153 care providers are beginning to find some painful as well as some beneficial ways to accommodate new realities. The committee is concerned that inaction may have consequences that would have deleterious effects on the level of health care. For some other fields (e.g., clinical laboratory technology and dental hygiene), there are factors that could cause instability in both demand and supply. For these fields the market is more likely to make the needed adjustments, and serious disruptions are less likely to occur. Yet there are unresolved issues in both of these fields concerning the match between tasks and levels and types of education. The way these issues are resolved could determine whether major imbalances will occur. The demand for and supply of speech-language pathologists, audiologists, respiratory therapists, and dietitians are expected to be sufficiently well balanced for the labor market to make smooth adjustments. The kinds of incremental adjustments that make careers attractive and the ways in which personnel are deployed appear likely to remain in a state of equilibrium over time. Nevertheless, changes in the factors the committee has identified as having major effects on demand and supply could cause disequilibrium. These factors should be monitored. These conclusions about the future outlook refer to the long term. For all fields, there are likely to be periods of greater and lesser imbalance between now and the year 2000. It is the nature of markets eventually to adjust to change. Projected imbalances in demand and supply do not mean that shortages or surpluses will occur. Rather, they signal that employers and potential employees must and probably will make adjustments. Only rarely are markets unable to accommodate changes in demand and supply through a variety of adjustment mechanisms. We have identified areas for potential adjustment in both demand and supply, which forms a basis for understanding future policy directions concerning supply and use of allied health personnel. The objective of policy is to make the process of adjustment less painful and less costly. Decrements in quality of care, interruptions or reductions of service, and curtailment of investment in new technologies and organizational forms (such as home care or HMOs) that might improve the efficiency of health care delivery are all possible by-products of personnel shortages. Any decision to intervene in the labor market is made through the political process and reflects society's willingness— or unwillingness—to tolerate painful dislocations. In many industries, such dislocations are viewed as normal and acceptable. Public policy actions have demonstrated that health care is viewed differently. The next three chapters of this report describe what educators, employers, and regulators, together with government, can do to facilitate the smooth working of the market.

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With estimates of their numbers ranging from one million to almost four million people, allied health care personnel make up a large part of the health care work force. Yet, they are among the least studied elements of our health care system. This book describes the forces that drive the demand for and the supply of allied health practitioners—forces that include demographic change, health care financing policies, and career choices available to women. Exploring such areas as credentialing systems and the employment market, the study offers a broad range of recommendations for action in both the public and private sectors, so that enough trained people will be in the right place at the right time.

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