Health Professions Workforce TPHA Ben G. Raimer, MD, MA, FAAP Chairman, Statewide Health Coordinating Council Senior Vice President, Health Policy The University of Texas Medical Branch Professor of Pediatrics, Family Medicine, and PM&CH April 23, 2010

Statewide Health Coordinating Council 17 member Governor Appointed Council Chapters 104 & 105 of the Health and Safety Code; updated by HB 1716 (Maxey, 75th legislative session) Development of the State Health Plan with focus on health care workforce planning 6 Year Planning Cycle with Biennial Updates The Texas State Health Plan 2005 – 2010 focused on the health workforce, noting that the SUPPLY of health professionals was critical because of: The aging workforce decreased enrollment in health professional schools due to a lack of qualified faculty due to a lack of competitive faculty salaries due to a lack of classroom space due to a lack of clinical training opportunities Societal trends feminization of the workforce (women work fewer hours per week than do men) life style preferences (more men and women health care professionals elect to have more time with family or in pursuit of personal interests than elect to work long hours) Failure to attract new graduates into jobs in rural and underserved areas Failure to address undesirable working conditions Inadequate “pipeline” supply (K – 12), especially math and science training Mal-distribution of health professionals Inadequate Texas GME slots 80% of Texas graduates stay in Texas if they complete their GME in Texas 50% of Texas graduates stay in Texas if they complete the GME in another state Texas currently lacks enough GME positions to meet the demand of its own graduates Lack of incentives for individuals to serve in HPSAs or MUAs Lack of specialty and locum tenens support in underserved areas Dramatic disparities in income among physicians, with those who practice in rural and underserved areas often earning much lower annual income than colleagues in metropolitan areas

Projected Population of Texas to 2040 millions Source: Texas State Data Center Population Projections

Projected Percent Change in Total Population in Texas Counties, 2008-2040 7

Data, Needs Assessment and Training Legislature passed into law new requirements for regulatory boards to provide licensure data on an annual basis to the Health Professions Resource Center Some regulatory boards: Lack the technology to comply with creation of the Minimum Data Set that permits HPRC analysis Do not track several key professionals in the health care delivery enumeration Enumeration of the health professions workforce and use of the Minimum Data Set by all the professions remains crucial if Texas is to understand its future workforce demands A comprehensive assessment of the Texas population is needed to assess the needs and plan for the development of its health professions workforce Although the legislature passed into law new requirements for regulatory boards to provide licensure data on an annual basic to the Health Professions Resource Center, some boards still lack the technology (and will) to comply with creation of the Minimum Data Set that permits HPRC analysis and study. In addition some boards do not track several key professionals in the health care delivery enumeration. In short, some are not required to maintain licensure and escape regulations especially in the clinical laboratory science area. Enumeration of the health professions workforce and use of the Minimum Data Set by all the professions remains crucial if Texas is to understand its future workforce demands.   Of equal importance is the role of the Texas State Demographer. A comprehensive assessment of the characteristics of the Texas population, its growth trends and prediction of future impact is absolutely necessary in order for Texas to assess the needs and plan for the development of its health professions workforce in the years to come.

Shortages and Maldistribution Texas leads the nation in population growth Texas ranks 42nd among 50 states in the ratio of physicians to population and 47th in ratio of nurses to population From 2000 to 2008, the Texas physician supply grew 21% while the number of Texans grew 19% PRIMARY CARE PHYSICIANS PER CAPITA (2008) (Graphic from HEALTHJOURNALISM.ORG) Expand enrollment to address shortage and mal-distribution of health professionals, needs of growing, aging population School of Nursing—increase enrollment 100% Example: Clinical nurse specialists, geriatric nurse practitioners, nursing faculty School of Health Professions—increase enrollment 100% Example: Physician assistants, clinical laboratory scientists, rehabilitation specialists School of Medicine—increase student enrollment 25%, grow residency programs 6

Shortages and Maldistribution There is a shortage of all health professions in Texas with the exception of LVNs Physicians, registered nurses, physical therapists, clinical laboratory scientists, occupational therapists, pharmacists, dentists, audiologists, and other health care professionals all number LESS per 100,000 population than the national averages In addition, the supply of health professionals in rural and border areas is even far LESS than it is in urban and non-border areas 73 percent of the counties in Texas are designated Health Professions Shortage Areas The most severe shortages in the health professions are in the area of mental health services There is a shortage of ALL HEALTH PROFESSIONS in Texas with the exception of LVNs. Physicians, registered nurses, physical therapists, clinical laboratory scientists, occupational therapists, pharmacists, dentists, audiologists, and other health care professionals all number LESS per 100,000 population than the national averages.   In addition, the supply of health professionals in rural and border areas (see attached maps) is even far LESS than it is in urban and non-border areas. Texas has a Health Professions Shortage Area designation for 121 whole counties and 65 partial counties. 73 percent of Texas counties are designated HPSA.

Shortages and Maldistribution Physicians in Direct Patient Care 2004 2009 Increase Percent Primary Care 15,374 16,830 1,456 9.6 Specialist 19,558 22,544 2,986 15.3 Total 34,932 39,374 4,442 12.7 Population (Millions) 22.4 24.8 2.4 10.5 The number of specialist physicians is growing faster than the State’s Population. The number of primary care physicians is not. Source: Tabulation of Texas Medical Board, Physician Licensure Database; Database maintained and supplied by Department of State Health Services, Center for Health Statistics, Health Professions Resource Center

Shortages and Maldistribution

Shortages and Maldistribution

Shortages and Maldistribution

Shortages and Maldistribution

Shortages and Maldistribution

Health Profession Diversity Texas has created programs to direct qualified minority students into the health professions Texas medical and nursing schools now boast some of the most diverse student body populations in the nation Outreach into the Latino student community continues to be a priority 36% of the 2007 Texas population is Hispanic Only 14.5% of Texas physician and dental students are Hispanic Only 13% of doctors in practice in Texas are Hispanic Texas must have systems in place that provide individuals from these important sub-populations the opportunities to seriously consider health care as a career, and they must also have the opportunities that lead to their successful application, entrance and graduation from health professions training Texas recognized a lack of diversity among its health professionals and set out over the past two decades to address this disparity. Recognizing the importance of cultural competence, language appropriateness, and racial and ethnic desirability, Texas has created programs to direct qualified minority students into the health professions. Texas has made progress in this area compared to other states, but still has a far piece to go. Texas medical and nursing schools now boast some of the most diverse student body populations in the nation.   Thirty six percent of the 2007 Texas population is Hispanic but only 14.5 percent of the Texas physician and dental students are of Hispanic origin. And, only 13 percent of doctors in practice in Texas are Hispanic. Outreach into the Latino student community continues to be a priority. To address issues related to diversity Texas must have systems in place that provide individuals from these important sub-populations the opportunities to seriously consider health care as a career, and they must also have the opportunities that lead to their successful application, entrance and graduation from health professions training.

Aging of the Workforce As the Texas population ages, so does the health professions workforce, but even more so The static size of entering classes causes disproportionate aging phenomena among the health care workforce Faculty in the state’s health professions schools, especially nursing faculty, also are older than comparable groups With an increased desire for retirement, both the numbers of professionals in active practice as well as those in university teaching positions are also decreasing dramatically The average age for a Marriage and Family Therapist in Texas is 60 years As the Texas population ages, so does the health professions workforce, but even more so. The static size of entering classes causes disproportionate aging phenomena among the health care workforce. Faculty in the state’s health professions schools, especially nursing faculty, also are older than comparable groups. With an increased desire for retirement, both the numbers of professionals in active practice as well as those in university teaching positions are also decreasing dramatically.

Specific Shortages and Special Programs Mental Health Professionals Dentists Pharmacists Mid-wives Clinical Laboratory Scientists Radiology Technologists Geneticists Physical Therapists Physician Assistants Pediatric Specialists Gerontologists Public Health Professionals The number of mental health professional trained to practice in Texas has failed to keep pace with the public demand. As more and more individuals seek treatment for mental health disorders, especially substance use, especially children and adolescents and geriatric patients, there is inadequate numbers of skilled professionals to keep pace with the demand for services. Texas has inadequate numbers of general psychiatrists, child and adolescent psychiatrists, geriatric psychiatrists, psychologists, substance abuse counselors, master’s level social workers, family therapists and counselor to keep pace with the demand.   As one would expect, these services are more often limited or inadequate in the rural and border areas of the state. Mental health professional shortage designations occur in 185 Texas counties. Restrictive regulation of telemedicine and telepsychiatry practice have also limited access to services for tens of thousands of Texans. Specific shortages also occur throughout Texas for dentists, pharmacists, mid-wives, clinical laboratory scientists, radiology technologists, geneticists, physical therapists, physician assistants, and other professionals.

Technology Health care professionals need new skill sets to utilize: Telemedicine Electronic Medical Record Digital Technology in Imaging Automation of Laboratory Diagnostics Pharmacy Management Systems Adoption of the preceding applications can address some geographic disadvantages as well as improve the quality and costs related to delivery of health care services The introduction and wide spread adoption of the electronic medical record, digital technology in imaging, automation of laboratory diagnostics, and pharmacy management systems requires a health professions workforce with new skills. Medical record librarians are quickly being replaced with information technology system analysts. Physicians and nurses must now be familiar with the keyboard of a computer. Pre-requisite skills in science, math, engineering, and technology are expected from applicants to most health professions schools. Soon, language competency in Spanish will likely be added to that skill set.   The widespread use of telemedicine to bring specialty services, mental health services and even primary care services into health profession shortage areas is a well documented, evidence-based medium with proved success in the Texas prison system and in other states such as Alaska, Hawaii, Idaho, Montana and others. Telemedicine can link remote and geographically disadvantaged patients with first class health care services. In Texas the regulatory and reimbursement environments have been slow to embrace this medium and its technology. There is no doubt that fostering the adoption of these applications can address some geographic disadvantage as well as improve the quality and costs related to delivery of health care services.

Educational Models Tele-technology for teaching, monitoring and mentoring students’ educational progress Preparing professionals to practice in a redesigned delivery model with a focus on the education, prevention, and management of chronic disease The most productive impact on the shortage of health care professionals Health care professionals must adopt new skill sets to address an increased demand for longevity, wellness, and performance The health care team of the future must focus its efforts on using knowledge and skills acquired through education and training at the right place, the right time, and the right cost The education of the health workforce increasingly requires inter-professional training. Perhaps it was really never realistic to train these professions in separate silos and then put them all together and expect teamwork. Today’s educational enterprise recognizes the importance of integrated, synergistic learning for all the health professions disciplines. Courses directed to integration of core learning objectives and specific competencies are now valued as more desirable for the best educational outcomes. Turf, tradition, territory and tenure have often slowed the process toward integrated curricula. Age old rules and regulations previously put into place to guard sacred turf are now being challenged. Innovations in education are desirable to create better performing professionals, to create better health outcomes for the patient, and to address the shortages in faculty.   In addition accrediting agencies and some health professions societies perpetuate outdated rules and regulations that are not in keeping with the best interests of patients and/or the public interests. Many have been slow to utilize tele-technology for teaching, monitoring and mentoring student’s educational progress, electing instead for more traditional human resource intensive models. These antiquated practices often impede the development of new educational models and slow the production of more health professionals entering the practice market. Preparing professionals to practice in a redesigned delivery model with a focus on the education, prevention, and management of chronic disease. Traditional roles and educational systems must be challenged. Society must find an acceptable way through education and prevention to address the issue of demand for health services. Health care professionals must adopt new skill sets to address an increased demand for longevity, wellness, and performance. The health care team of the future must focus its efforts on using knowledge and skills acquired through education and training at the right place, the right time, and the right cost.

Texas - Mexico Border Issues Primary Care Physician Supply Ratios – 2007 by Border and Non-Border Counties The pipeline for individuals to enter the health professions requires careful evaluation. Kindergarten through Grade 12 programs are essential in all areas of the educational enterprise to assure that youth are introduced to the career options in health at an early age. This is perhaps even more important in rural, border and under-served areas. Many children in Texas actually reach high school graduation without exposure to a wide array of health professions in their knowledge base. Children must be introduced to science, technology, math, and related areas in order to be able to excel in pre-medical curricula.   Career awareness programs that acquaint students at and early age with their options for careers in health are very important if we are to meet the demands for future workforce. Prepared By: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services, May 28, 2008

Health Disparities / Chronic Diseases Differences in mortality and morbidity rates are significant among racial and ethnic groups in Texas, across geographic boundaries, and between urban and rural areas Disparities impact population productivity and add to the overall costs of health care Access to mental health services is most disparate among African-American and Hispanic populations Chronic Diseases Chronic Diseases such as diabetes, hypertension, cancer, heart failure and asthma affect thousands of Texans Prevention and management of patients with chronic illness has the potential to save Texans millions of dollars in health care costs Behavioral Health The pipeline for individuals to enter the health professions requires careful evaluation. Kindergarten through Grade 12 programs are essential in all areas of the educational enterprise to assure that youth are introduced to the career options in health at an early age. This is perhaps even more important in rural, border and under-served areas. Many children in Texas actually reach high school graduation without exposure to a wide array of health professions in their knowledge base. Children must be introduced to science, technology, math, and related areas in order to be able to excel in pre-medical curricula.   Career awareness programs that acquaint students at and early age with their options for careers in health are very important if we are to meet the demands for future workforce.

Health Professional Shortage Areas for Mental Health As of March 10, 2009 there were 172 whole county Health Profession Shortage Areas (HPSAs) for mental health, and 12 sub-county geographic or special population HPSAs in Texas Prepared By: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services, August 6, 2009

Health Profession Action Plan Assure that every Texan has access to local health care services for wellness, prevention, acute care, chronic care, behavioral health services, and specialty services Assure that Texas has a culturally competent, linguistically appropriate, and state-of-the art trained health professions workforce that utilizes evidence-based decision making to assure that Texans receive quality, safe health care at reasonable costs Assure that the Texas health professions infrastructure has access to state-of-the-art electronic health records, telemedicine services, and decision support services that set the highest standards for health care delivery Assure that no Texan goes without prevention and educational services related to wellness and chronic disease management

Preparing the Health Profession Workforce Sustain those state programs that have demonstrated a positive impact on the recruitment of students into the professions JAMP T-STEM Sustain scholarship and loan repayment programs for health professionals electing to practice in underserved areas Assure that diversity and cultural / language competencies are valued in the long-term development of Texas’ workforce Sustain and expand community programs through AHEC and ORCA that provide student mentoring and career development in the health professions Expand the training of Community Health Workers

Workforce Requirements for Health Reform Expand Graduate Medical Education (GME) programs Primary Care Specialty Care Expand the graduation rates of nursing and allied health science professionals Expand the number of behavioral health professionals Create innovative models for health care delivery Inter-professional teams for management of chronic disease Re-visit scope of practice standards for advanced practice nurses and physician assistance Re-visit scope of practice for psychologists, MSWs and other mental health professionals Expand the services available to patients through community health centers (FQHCs) Incent professionals who elect to practice in underserved areas Scholarships, loan repayment Preferential reimbursement