Appropriate access to high-quality care is a priority for patients and policy makers alike. Though many social and economic factors influence access to care, one important domain that affects timely access is the adequacy of the health care workforce supply. When the capacity of the workforce enables patient needs to be met, capacity is adequate. When the capacity of the workforce is insufficient, access to care will be suboptimal. Increases in workforce capacity can be achieved in one or more of the following ways: increase the workforce supply (eg, the number of physicians being trained), reduce attrition of the workforce (eg, physician retirement or shifting to nonclinical roles), train others to take over some aspects of the work effort (eg, physician assistants, nurse practitioners, and others who serve a substitution role for traditionally physician-centric activities), and increase efficiency/reduce waste (eg, reduce time spent on documentation and use the time gained on direct patient care) (Table 2-1).
U.S. Healthcare Workforce Supply and Projected Growth Through 2025
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U.S. Healthcare Workforce Supply and Projected Growth Through 2025
| ||Current supply (in FTE) ||Projected supply (FTE) in 2025 (increase relative to current supply) ||Is projected supply adequate to meet projected demand? |
|Physicians (MD, DO) || || || |
|Primary care ||216,580 ||239,460 (11%) ||No |
|Nonprimary care ||498,800 ||602,700 (21%) ||No |
|Advance practice nurses (APN, NP) || || || |
|Primary care ||57,330 ||110,540 (93%) ||Yes |
|Nonprimary care ||126,900 ||306,000 (141%) || * |
|Physician assistants (PA) || || || |
|Primary care ||33,390 ||58,770 (76%) ||Yes |
|Nonprimary care ||52,500 ||109,300 (108%) || * |
|Nurses (RN) ||2,897,000 ||3,849,000 (33%) ||Yes |
The evolving needs of patients, coupled with new models of reimbursement and care delivery in the United States, are driving significant change in the health care workforce of the 21st century. New health professional and paraprofessional roles are emerging, and traditional roles are being reimagined as the concept of team-based care becomes increasingly standard to high-quality, high-value care delivery. Care innovations such as telehealth accentuate the need for new skills and new roles in the health care workforce.
For several years, concerns have mounted about the adequacy of the supply of physicians in practice, particularly in light of the aging of the U.S. population, with its greater burden of chronic diseases. The Association of American Medical Colleges projects a physician shortage ranging between 61,700 and 94,700 by the year 2025. 1 Workforce projections have historically been imprecise in predicting physician shortages or surpluses. However, a 20-year cap on the number of residency positions funded through the Medicare program (the principal funder of graduate medical education) and an aging workforce in many areas of the country create a context for concern. In particular, concerns are widespread about a shortage of primary care physicians among numerous professional organizations and the federal government. The Health Resources and Services Administration (HRSA) estimates that there were just over 215,000 full-time–equivalent primary care physicians in 2013 and projects 11% growth in supply by 2025. However, HRSA predicts that demand for primary care services will grow by 17% in this same time span. 2
There has been tremendous growth in the number of advanced practice providers, namely physician assistants and advanced practice nurses, which will help to offset the projected shortage of physicians. Indeed, by 2025 the supply of physician assistants is projected to increase by 50%, an estimate that does not take into account ongoing growth in the number of PA training programs opening across the country. 3 Similarly, the supply of advanced practice nurses graduating annually more than doubled between 2002 and 2012, with ongoing growth in supply anticipated. 4
Separate from the advanced practice nursing workforce, the nursing workforce has undergone substantial growth, doubling the number of diploma RN graduates from 68,000 to 150,000 annually between 2001 and 2013. The growth of the nursing workforce in the past decade has completely mitigated previous projections of a severe nursing shortage. Indeed, workforce planners now project that the supply of nurses will meet or exceed demand through 2025. 5
There are, of course, numerous additional roles that are essential to delivering the full complement of health care services. Traditional personnel, ranging from doctoral-trained pharmacists to certificate-level medical assistants, are adapting into new roles, often with a more direct hand in delivering care to patients. Pharmacists, for instance, actively participate in medication management, adherence, and safety oversight in both inpatient and ambulatory clinical settings. Using care protocols and templates, medical assistants are serving a diverse set of roles in the ambulatory setting, from initiating patient visits by collecting relevant history, scribing for the physician in the electronic medical record, and finally closing visits by ensuring that patients understand the plan of care and scheduling follow-ups as needed. A similar diffusion of roles and settings of work is underway for many allied health professionals, such physical therapists and dietitians. New roles have also emerged, including health coaches, community health workers, and nurse care coordinators. Many of these positions have been created in an effort to target population health improvement, often by focusing on those individuals with more complex health and/or social needs.
As roles emerge and evolve to meet the needs of patients and the realities of an increasingly complex delivery system, it can be difficult to project adequate workforce capacity accurately. However, one certainty in this time of rapid change in delivery is the need for all health care professionals to have a high degree of adaptability and a willingness to work effectively in teams, including a high level of communication and coordination. New technologies can facilitate communication and coordination, but to do so they must be harnessed through concerted efforts by health professionals and information technology professionals to be an asset rather than a barrier.
Overall estimates of health care workforce supply can obscure areas of particular need. A prime example is in behavioral and mental health services, including services for substance use disorders. A wide range of health care professionals serves the behavioral and mental health needs of the population, including (but not limited to) psychiatrists; clinical, counseling, and school psychologists; substance abuse and behavioral disorder counselors; mental health and substance abuse social workers; mental health counselors; and school counselors. HRSA projects a substantial shortage of all of these behavioral and mental health professionals in the coming years. 6
The geographic distribution of the workforce has been a persistent problem for access to care that has defied solution to date, despite widespread recognition by health workforce planners and researchers. Years of research have demonstrated that in the midst of overall growth in the health care workforce, there are tremendous variations in the local and regional supply of physicians and other clinicians. Furthermore, physicians entering the workforce disproportionately tend to settle in areas that are already well populated by their peers. 7 This leaves many rural and inner-city communities without the physicians and other clinicians they need. This problem persists despite national efforts such as the National Health Service Corps, which specifically targets workforce development for underserved areas through incentives such as scholarships and loan repayment programs for those who practice in needed fields within such regions. Many states offer similar incentives to attract providers to underserved communities. Even when a small town has an adequate supply of primary care providers, it may not be able to support subspecialists due to its limited size. The result is an urban–rural maldistribution of specialists, which presents a significant burden on patients when the services of a subspecialist are required, particularly in regions with long distances to drive or geographic barriers (such as mountain ranges) that make travel difficult and risky at certain times of the year.
Thus, health care in the contemporary digital era has experienced a transformation driven by need, workforce shortages, consumer demand and engagement, innovations in technology, expansions of broadband communications services, and innovative “connected health” care delivery models. 8,9 Advancements in state and federal public policy, coupled with greater engagement by providers, payers, employers, and consumers, have led to new paradigms of care enhanced by telemedicine. Not a specialty in and of itself, telemedicine and telehealth offer tools to address the significant challenges of access, quality, and cost—the “triple aim” articulated by the Institute for Healthcare Innovation. 10,11
The American Telemedicine Association (ATA) defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status.” 12 Telehealth generally refers to a broad range of health-related services across a wide range of disciplines supported by telecommunications technology that includes telemedicine, as well as health-related distance learning, remote patient monitoring, call centers, consumer-facing virtual and e-health applications, and other services that enhance health but do not necessarily represent the delivery of clinical care.
A number of definitions of telemedicine and telehealth are used by both federal and state agencies. 13 HRSA, home to the federal Office for the Advancement of Telehealth (OAT), defines telehealth as “[t]he use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration.” 14 State definitions vary and often include definitions in code, such as that of California: “The mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.” 15 Virginia code specifically defines telemedicine as “the use of electronic technology or media, including live interactive audio or video (IAV), for the purpose of diagnosing or treating a patient or consulting with other healthcare providers regarding a patient's diagnosis or treatment.” 16
Telemedicine includes a growing variety of applications and services using two-way videoconferencing, either with or without the use of peripheral devices, store and forward asynchronous technologies, mobile and wireless tools through which clinical care is provided, and hybrids between these three options. There is considerable overlap in care delivery models provided through mobile (m-health) technologies using high-speed and lower-bandwidth telecommunications networks.
Examples of telehealth-related services include a) video-based specialty and primary care consultations and follow-up visits, with or without the use of peripheral devices appropriate to the patient's condition; b) store and forward services—the asynchronous transfer of patient images and data for interpretation by the clinician not necessarily in the presence of the patient (eg, teledermatology, teleophthalmology); c) hybrid models of (a) and (b) to support patient care, including electronic intensive care unit (ICU) care models; d) remote patient monitoring, including the collection and transfer of biometric data to a monitoring facility or agency (eg, daily weight, heart rate, blood pressure, blood sugar, oximetry, electrocardiogram [ECG], gait); e) mobile health services that support the earlier models; f) patient and provider health education; and g) e-consults between providers. 17,18 These models will be addressed in subsequent chapters.
Live-interactive (synchronous) face-to-face telemedicine connections are provided over secure high-definition endpoints and/or other video technologies and include provider-to-patient encounters, provider-to-provider video-based consultations, group case management discussions (such as tumor boards or case conferences), and provider-to-patient educational programs. A broad range of digital peripheral devices (eg, specialty cameras, electronic stethoscopes, otoscopes) can support clinical encounters with the goal of replicating in-person care. It should be noted that some teleconsultants are providing services using security options that are less than ideal (eg, Skype, FaceTime) and these are not recommended or approved by the majority of health care systems.
Store and forward (asynchronous) services include (but are not limited to) radiographic and pathologic studies, photos, patient data, and video clips of patient examinations. These services may maximize provider efficiency when sufficient data are provided to support the clinical service requested to render a diagnosis. Peripheral devices may also support the acquisition of clinically relevant data for store and forward encounters.
Remote patient monitoring utilizes digital technologies to collect and transmit patient data (eg, ECGs) to providers for assessment and follow-up care, for chronic disease management, postacute hospitalization readmissions prevention, and many other applications. Although not always, most of these devices are approved (cleared) by the Food and Drug Administration (FDA) and are devices typically used during face-to-face encounters but have been adapted for remote data collection and transmission. They are generally prescribed by a provider for patient use for both short- and long-term data collection periods.
Mobile health (m-health) technologies blend the earlier services when acquired via mobile devices, including smart phones, and sensing devices (eg, FitBit) facilitated by application software downloaded onto mobile devices (apps). Peripheral devices can also be used to acquire images and data through mobile technologies. Although not always, the majority of these data collection devices and apps are not FDA approved/cleared, and the provider may choose whether or not to accept such data for use in patient care.
E-consults include secure electronic communications between providers (such as primary care to specialist) or between providers and patients where permitted by applicable statute and regulation. Such platforms can improve care coordination, enhance timely access to specialty care, and potentially lower the cost of care through improved case management.