 

   
 
 

 
   
 

 

 

 

 

 

 

 
 

 

 

 

Alieel
HEALTH

 

Services

Avoiding Crises

Committee to
Study the Role of Allied Health Personnel

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, DC. 1989

NATIONAL ACADEMY PRESS ' 2101 Constitution Avenue, NW - Washington, DC 20418

NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their special competencies and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences
to enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy‘s 1863 congressional charter responsibility to be an advisor to the federal gov-
ernment and its own initiative in identifying issues of medical care, research, and education.

This project was supported by the Health Resources and Services Administration, HRSA
Contract No. 240-86-0066.

Library of Congress Cataloging-in-Publication Data
Allied health services: avoiding crises / Committee to Study the Role
of Allied Health Personnel, Institute of Medicine.
p. cm.
Bibliography: p.
Includes index.
ISBN 0-309-03929-0. —ISBN 0—309-03896-0 (pbk.)
1. Medical policy—United States. 2. Allied health personnel—
Government policy—United States. 3. Paramedical education—
Government policy—United States. 1. Institute of Medicine
(U.S.). Committee to Study the Role of Allied Health Personnel.
RA395.A3A479 1988 88-37922
362.1’7—dc19 CIP

Printed in the United States of America

{A 3973’
’4; [SIM

COMMITTEE TO STUDY THE ROLE OF ALLIED
HEALTH PERSONNEL (kl/7

WILLIAM RICHARDSON,* Chairman, Executive Vice President and P“ (g L
Provost, Pennsylvania State University

jOHN E. AFFELDT,* Medical Advisor, Beverly Enterprises, Pasadena,
California

STANLEY BAUM,* Professor and Chairman, Department of
Radiology, Hospital of the University Of Pennsylvania

FLORENCE S. CROMWELL,* Consultant in Program Development, and
Editor, Occupational Therapy in Health Care, Pasadena, California

E. HARVEY ESTES,* Director, Family Medicine Division, Department
of Community 8c Family Medicine, Duke University Medical School

GARY L. FILERMAN, President, Association Of University Programs in
Health Administration, Arlington, Virginia

POLLY FITZ, Professor, School of Allied Health Professions,
University Of Connecticut

ALGEANIA FREEMAN, Dean, School of Public and Allied Health, East
Tennessee State University

SISTER ARLENE McGOWAN, Vice President for Operations,
Providence Hospital, Cincinnati, Ohio

ROBERT E. PARILLA, President, Montgomery Community College

EDYTHE H. SCHOENRICH, Director, Continuing Studies, johns
Hopkins School of Public Health

C. EDWARD SCHWARTZ, Executive Director and Vice President for
Medical Center Hospital Of the University Of Pennsylvania

‘FRANK SLOAN,* Chairman, Department of Economics, and Director,
Health Policy Center, Vanderbilt Institute for Public Policy Studies,
Vanderbilt University

PAUL M. STARNES, Assistant Superintendent, Hamilton County
Department Of Education, and Member, Tennessee House of
Representatives, Chattanooga

REED STRINGHAM, Dean, School Of Allied Health, Weber State
College

MYRA STROBER, Professor Of Economics, School of Education,
Stanford University

RHEBA DE TORNYAY,* Professor, School of Nursing, Director, RWJ
Clinical Nurse Scholars Program, University of Washington

NANCY WATTS, Professor Of Physical Therapy, Massachusetts
General Hospital Institute Of Health Professions, Boston

*Member, Institute of Medicine

iii

Study Staff

KARL D. YORDY, Director, Division of Health Care Services
MICHAEL L. MILLMAN, Study Director

SUNNY G. YODER, Associate Director

JESSICA TOWNSEND, Research Associate

MARYANNE P. KEENAN, Research Associate

CAROL C. MCKETTY, Research Associate

DELORES H. SUTTON, Secretary

WALLACE K. WATERFALL, Editor, Institute of Medicine

Consultants

NAOMI BOOKER
RUTH BROWN
EUGENIA CARPENTER
NURIT ERGER
HAROLD GOLDSTEIN
OLIVE M. KIMBALL
EDMUND]. MCTERNAN
RICHARD MORRISON
BILL WALTON

iv

 

Preface

THIS REPORT 15 THE RESULT of an 18-month study by. the Committee
to Study the Role of Allied Health Personnel of the Institute of Med-
icine to explore policy issues that surround the roles of allied health per-
sonnel. It was prompted by a congressional mandate contained in Public
Law 99-129, the Health Professions Training Act of 1985 (Appendix A)
and implemented through a contract with the Health Resources and Ser-
vices Administration of the Department of Health and Human Services.
The study is the ﬁrst major independent examination of the diverse set of
health care occupations that often fall under the umbrella term allied health.

STUDY BACKGROUND

Although some allied health ﬁelds such as dietetics date back to the
nineteenth century, it was the federal health professions legislation of the
19605 that gave life to the concept of a collectivity now known as allied
health personnel.

Despite the withdrawal of most direct federal support for allied health
education in the early 19805, allied health leaders convinced Congress that
such a large part of the health care work force (estimated at from 1 to
almost 4 million people) should not continue to go unmonitored and un-
studied, especially when so much about the health care system is under—
going sweeping change. Some factors in this reshaping include increasing
pressure from both the public and private sectors to curtail costs; the
introduction of new, sophisticated health technologies; growing numbers
of elderly patients; increasing attention to individuals with chronic disa—

V

Vi PREFACE

bilities; and drastic developments in disease, such as the acquired immune
deﬁciency syndrome (AIDS) epidemic.

How the health care system adapts to these pressures depends in large
part on whether workers with the requisite education are available at the
right place and time. Consequently, a careful assessment of future person-
nel needs has never been more important than it is now. Making sound
policy decisions about education, regulation, and other matters that affect
the demand for and supply of allied health personnel is difﬁcult, however,
in part because allied health personnel have been among the least studied
elements of the health care system. In response to this deﬁciency, Congress
in 1985 mandated this national study.

INTERPRETATION OF THE CONGRESSIONAL CHARGE
Congress posed ﬁve tasks for the study:

1. Assess the role of allied health personnel in health care delivery.

2. Identify projected needs, availability, and requirements of various
types of health care delivery systems for each type of allied health personnel.

3. Investigate current practices under which each type of allied health
personnel obtains licenses, credentials, and accreditation.

4. Assess changes in programs and curricula for the education of allied
health personnel and in the delivery of services by such personnel that are
necessary to meet the needs and requirements identiﬁed pursuant to
item 2.

5. Assess the role of federal, state, and local governments, educational
institutions, and health care facilities in meeting the needs and requirements
identiﬁed pursuant to item 2.

These inquiries were not raised in the speciﬁc context of existing or
proposed federal legislation but rather from a broader concern that a large
body of health care workers had received insufﬁcient attention in relation
to their importance in future health care. In effect, Congress asked for
information about this major component of the health work force to de-
termine whether corrective action was needed, and if so, where responsi-
bility for such action rested.

The study committee was directed to assess the role of allied health
personnel in the delivery of health care. It has interpreted this charge as
a request for better information about the ways in which allied health
practitioners are deployed, their functions, their relationships with other
health care practitioners, and the settings in which they work. In addition,
the committee has interpreted the charge as a need to elucidate the various
factors and forces—education and training, employer requirements, third-

PREFACE Vii

party payer policies, and the regulatory apparatus, to name several of
importance—that shape that role.

The second item in the congressional charge, in effect, asks the committee
to provide its best judgment as to whether the needed future services of
allied health practitioners will be available. This task in turn raises questions
about the way the allied health labor market operates and whether market
adjustments can be expected to take place (for instance, salary increases,
if the demand for personnel should outpace supply) before service dislo-
cation or quality erosion occurs. Although much of the report addresses
the likely future market demand for allied health workers, the committee
has not overlooked the fact that there may be some important service needs
that are not being met now. Long-term care is a current example of the
way a lack of good jobs and reimbursement can undermine the nation’s
ability to supply certain basic services.

In the charge’s third item, Congress requests an examination of licensure
and other forms of credentialing in allied health ﬁelds. The committee
believes this request expresses concern about the imbalance between the
costs and inefﬁciencies of regulation on one hand and the need to protect
consumers from poor quality care on the other. To make the desired
adjustments, we need a better understanding of the current situation, the
contribution of regulation to quality, and the diverse costs of regulation.

The fourth item of the congressional charge—an examination of edu-
cation programs and curricula—arises from concerns about whether allied
health education is now and can remain in step with the changing nature
of health services. The committee also interpreted this segment of the
charge to include a consideration of whether allied health education pro—
grams are likely to be able to compete for higher education resources and
for students interested in pursuing technically oriented careers. '

The final congressional request is for an assessment of the abilities of
major legislative, educational, and health care entities to make the necessary
adjustments that will ensure that allied health personnel can fulfill their
potential in the health care delivery system of the future. Some of the
questions for which the committee sought answers in this regard included
the following: If intervention is needed, who has the final responsibility
and leverage to act, and how can they know when and how to intervene?

STUDY APPROACH

To address the questions posed by Congress, the committee and study
staff solicited information from a broad array of organizations, including
the allied health professional associations, state regulatory agencies, and
higher education coordinating bodies, and federal agencies such as the

viii PREFACE

Bureau of Health Professions and the Bureau of Labor Statistics. In ad-
dition, the committee held two workshops with invited experts and a public
meeting on the regulation of allied health personnel. The ﬁrst of the two
workshops concerned the future demand for allied health workers; the
second concerned education and the supply of workers. (Appendix B is a
list of the participants at each of these meetings.) Study staff and committee
members also visited health care provider institutions, including several
long-term care facilities, health maintenance organizations, and a multi—
hospital system.

The committee has not collected primary data but instead has used
existing data from a variety of sources to focus on important issues. These
issues were explored primarily through an examination of 10 allied health
ﬁelds. Individually, these ﬁelds reﬂect different facets of allied health oc-
cupations; collectively, they reveal some common threads in the way all
allied health fields can respond to the challenge of a changing health care
system.

This study is a ﬁrst step toward addressing a neglected topic in health
care policy. The committee did not have the beneﬁts of either large—scale
sample surveys or an extensive body of empirical literature. Recognizing
that a rich data base may not be in the immediate future for allied health,
the committee has suggested strategies for enhancing existing data to im-
prove the grounds on which decision makers act.

Allied health is an ill-deﬁned term. Because there is no consensus about
which occupations constitute allied health, and because the more compre-
hensive deﬁnitions encompass so many ﬁelds that study is impracticable,
the committee settled on a set of fields that exclude some occupations that
readers might expect to ﬁnd. Among those excluded are nurses, nurse
practitioners, midwives, physician assistants, pharmacists, and social work-
ers and mental health counselors. Guiding the committee’s selection of
study ﬁelds was the federal health professions legislation and the need to
cast light on large but relatively unstudied occupations.

MAJOR STUDY THEMES

The following report is intended for a wide audience: allied health
professional organizations, administrators at educational institutions, state
regulatory and licensing bodies, employers of allied health personnel, and
policymakers at both the state and federal levels. Although the study’s
ﬁndings are most often based on national data and trends, the analysis is
intended for use by all “actors” in the ﬁeld who are looking to the future,
including those at the local level—the college administrator considering
whether to offer allied health programs, the legislator voting on a licensure

PREFACE ix

law, the home care agency administrator setting salary levels for employees,
and the therapist considering whether to establish an independent practice.

The reader may wish to be alert for several themes that have guided
the committee in determining areas for its recommendations. These themes,
which were derived from the study activities and are interwoven throughout
the report, include the following:

0 allied health personnel as an under-recognized but important human
resource;

0 the need for data and research to provide the basis for more effective
use of allied health personnel;

0 the need for health care and educational institutions to assist each
other in adjusting to new realities in the way services will be delivered in
the future;

0 the fragility of some of the education programs that provide new
entrants into the allied health ﬁelds;

0 the importance of competitive levels of compensation in a labor market
in which individuals with technical- and service-oriented skills will be at a
premium; and

o the need to balance quality concerns with those of cost, ﬂexibility, and
employment opportunity in the regulatory policy arena.

ORGANIZATION OF THE REPORT

Chapter 1 introduces the subject of the study, allied health occupations,
and brieﬂy traces the evolution of 10 fields. Chapter 2 examines various
data sources and discusses ways to forecast the demand for and supply of
allied health personnel. Chapter 3 looks at such forces as demography,
disease patterns, the structure of the health care delivery system, and wom-
en’s study choices, all of which affect allied health personnel demand and
supply. Chapter 4 reviews national projections of the demand for allied
health workers through the year 2000 and presents the committee’s as-
sessment of that demand and its own assumptions and projections of
supply.

In Chapter 5 the committee addresses the contribution of educational
output to future supply. Recommendations are offered to increase the
recruitment of students, including minority students, into allied health
education programs and to improve the capacity of educational institutions
to support such programs. Chapter 5 also discusses the levels and content
of education needed to prepare practitioners for the future work force.

In presenting the employer’s perspective in Chapter 6 the committee
reviews some of the available options for correcting and adapting to per-

X PREFACE

sonnel supply imbalances and charts a role for health care administrators
in enhancing the size and effectiveness of the allied health work force.

Chapter 7 describes the various mechanisms of control of allied health
personnel, focusing principally on the problems state legislators face in
making decisions about licensure and other forms of occupational regu-
lation. The chapter emphasizes the need for ﬂexibility in the functions of
allied health personnel. Finally, Chapter 8 takes up long-term care and the
needs it poses for allied health personnel.

WILLIAM RICHARDSON
Chairman

 

Acknowledgments

THE COMMITTEE GRATEFULLY acknowledges the contributions of many
people and organizations who provided assistance and information to
this study. Chief among the organizations are the allied health professional
associations themselves. Despite apprehensions from time to time about
what conclusions and recommendations the committee might produce,
these organizations generously rose to the challenge of providing the in-
formation the committee requested. The committee solicited input from a
wide-ranging set of allied health associations and wishes to thank each of
them. Special acknowledgments, however, are in order for those associa-
tions representing the 10 ﬁelds studied in-depth, as well as the American
Society of Allied Health Professions and the National Society of Allied
Health Professions. The committee was also aided by Dr. Gerry Kaminski,
Dean of Cincinnati Technical College, who provided us with information
from the organization of two-year college allied health deans on allied
health programs in community colleges.

Several government agencies provided critical assistance in the use of
federal data systems. Our deepest thanks go to Ann Kahl and her staff,
Sandy Gamliel, Steven Tise, and William Austin, who spent considerable
time with the staff discussing the Bureau of Labor Statistics (BLS) meth-
odology and their work on specific allied health ﬁelds. Alan Eek, also of
the BLS, generously offered his expertise in the areas of supply and oc-
cupational mobility. Debra Gerald of the US. Department of Education
was extremely helpful in providing the committee with higher education
projections. Numerous individuals in the central office and facilities of the
Veterans Administration were willing to describe their experiences in re-

xi

xii ACKNOWLEDGMENTS

cruiting, retaining, and educating allied health staff. Above all, we wish to
thank our sponsors, the Bureau of Health Professions, Health Resources
and Services Administration. Tullio Albertini, the study project officer, and
other staff members were eager to meet the committee’s needs for guidance
and information throughout the study.

We also wish to acknowledge a number of institutions who welcomed
committee members and staff, allowing us to tour their facilities and speak
to allied health personnel in the workplace. These institutions include the
Sisters of Mercy Health Corporation, Harvard Community Health Plan,
Rancho Los Amigos Medical Center, Beverly Manor Convalescent Hospital,
On Lok Senior Health Services, Garden Sullivan Hospital, VA Medical
Center Palo Alto, Durham County General Hospital, Beverly Health Care
Center, Tarboro, NC, and the Berry Hill Nursing Home.

Our thanks also go to] Warren Perry, Alexander McMahon, and John
DiBiaggio for attending committee workshops and providing advice to
committee and staff.

Finally, we wish to thank all those individuals (listed in Appendix B) who
participated in our public hearings and workshops. '

WILLIAM RICHARDSON
Chairman

 

Contents

Executive Summary .................................................. 1
1 What Does “Allied Health” Mean? ........................... ‘15
2 Approaches to Measuring Demand and Supply ........... 44
3 Forces and Trends in Personnel Demand and Supply 63
4 Demand and Supply in 10 Allied Health Fields ........... 96
5 The Role of Educational Policy in Inﬂuencing Supply 159
6 The Health Care Employer’s Perspective ................... 206
7 Licensure and Other Mechanisms for Regulating

Allied Health Personnel ......................................... 235
8 Allied Health Personnel and Long-Term Care ............ 259
APPENDIXES
A. Congressional Mandate ......................................... 283
B. Participants in Workshops and Public Meetings ........... 285

C. A Sample of Allied Health job Titles and a
Classiﬁcation of Instructional Programs in
Allied Health ...................................................... 291

xiii

xiv CONTENTS

D. Estimates of the Current Supply of Personnel in 10
Allied Health Fields ............................................. 296
E. PnjecuonsoflknnandzuulSuppb/niCkruanOns ....... 303
F. Minnesota Sunrise Provisions .................................. 319
G. National Commission for Health Certifying Agencies’
Criteria for Approval of Certifying Agencies .............. 324
H. Source Material ................................................... 329

Index ................................................................... 331

Allied

 

HEALTH

 

Serviws

 

Executive Summary

THIS REPORT 15 THE RESULT of the first large, national study of the
enterprise known as allied health. It identiﬁes the major functions of
allied health practitioners, a group that has been relatively unrecognized
by health policymakers. A major consequence of this low profile has been
that policymakers are often unaware of the impact of their decisions on
allied health services.

Allied health personnel constitute a majority of the health care work
force. They work in all types of care—primary, acute, tertiary, and chronic—
and in all health care settings—physicians’ and dentists’ offices, health
maintenance organizations, laboratories, freestanding facilities offering special
services, ambulances, home care, and hospitals. The levels of training of
allied health personnel are as varied as the care they provide and the settings
in which they work. These personnel include both highly educated persons
and others with only on-the—job training. They work with widely varying
degrees of autonomy, dependence on technology, and regulation.

Yet there is a paucity of information about them. There is not even a
consensus on what the term allied health means. Compared with nurses,
physicians, and dentists, the allied health work force as a whole has been
little studied. Prompted by a congressional mandate and funded by the
Health Resources and Services Administration of the US. Department of
Health and Human Services, this study by the Institute of Medicine was
intended to answer the following questions: First, what roles do allied health
workers perform and how will these roles fit into a changing health care
delivery system over the next 15 years? Second, what will be the future
demand for allied health personnel and how can public and private poli-

l

2 ALLIED HEALTH SERVICES

cymakers ensure that that demand is met? Third, should these occupations
be regulated and, if so, how? Fourth, what sorts of actions should educators
take to prepare allied health practitioners for the workplace of the future?

The committee’s recommendations are based on what existing evidence
tells about vital characteristics of the allied health labor market:

0 the composition of the labor force—namely, the predominance of
technically competent women with a service orientation;

0 highly regulated professions and work environments;

0 education programs that are unable to compete effectively with other
academic programs for limited resources and sufﬁcient numbers of stu-
dents; and

0 employers whose organizations are undergoing sweeping changes in
their ﬁnancial incentives and who must make hiring, compensation, and
work force allocation decisions in the absence of good information.

Throughout the study a major challenge for the committee has been to
capture the diversity of allied health occupations and at the same time
devise speciﬁc yet encompassing recommendations for those who must
make policy decisions that affect allied health personnel. Toward this end
the committee chose to focus on 10 allied health ﬁelds. It used the following
criteria in their selection: (1) each of the 10 must be large and well known;
(2) collectively, they must span the spectrum of autonomy; and (3) collectively,
their practitioners must work in a wide variety of health care settings.

The occupations that were selected include clinical laboratory technol-
ogists and technicians, dental hygienists, dietitians, emergency medical per-
sonnel, medical record administrators and technicians, occupational therapists,
physical therapists, radiologic technologists and technicians, respiratory
therapists, and speech—language pathologists and audiologists.

It is the committee’s hope that this report is only the beginning of a
process that will clarify the place of all allied health occupations in the
health care delivery system.

ALLIED HEALTH PERSONNEL: WHO ARE THEY AND
WHAT DO THEY DO?

There have been many attempts to deﬁne allied health and to categorize
the occupations that should be covered by this umbrella deﬁnition. Lacking
a satisfactory deﬁnition of allied health, however, efforts to classify occu-
pations have focused on speciﬁc aspects of work and education (e.g., pa-
tient-oriented groups versus laboratory-oriented groups) or on the level of
education needed. The results of these attempts have not been enthusi-
astically embraced by allied health practitioners. The committee chose not
to join in the search for a deﬁnition. The beneﬁts of making the term more

EXECUTIVE SUMMARY 1 3

precise are less clear than the beneﬁts of continued evolution. The changing
nature of health care makes some practices and practitioners obsolete at
the same time it opens up opportUnities for the formation of new groups.
It is more important that pragmatism continue to prevail and that old and
new groups draw what beneﬁts they can from belonging to “allied health”
than that a description of common characteristics deﬁnes the group.
Rather than deﬁne allied health, the committee thus chose to examine
policy-related characteristics of occupations that help explain how the fields
are variously affected by changes in the health care environment. These
characteristics include the amount of autonomy in the workplace, the oc—
cupation’s dependence on technology, the substitution of one level and
type of personnel for another, ﬂexibility in the location of employment,
degree of regulation, and inclusion in accreditation standards for facilities.

ESTIMATING SUPPLY AND DEMAND

To respond to the congressional charge “to identify projected needs,
availability, and requirements of various types of health care delivery sys-
tems for each type of allied health personnel,” the committee had to resolve
issues of scope and approach. Given its limited funds and time the com-
mittee concluded that its greatest contribution would be to try to clarify
the future outlook for allied health personnel—which is crucial to strategic
planning and policy—rather than to systematically assess the current sit-
uatlon.

Data Limitations

The committee’s ability to fulﬁll its charge was severely hampered by a
lack of data, the result of a relatively low interest and small investments of
public resources in learning about the allied health work force. The com-
mittee had to rely on data sources that included some information about
allied health, however incomplete and unreliable those sources might be.
It assessed the existing data and conducted hearings, site visits, and work-
shops to round out its own expertise and enhance its understanding of the
forces that will shape the future of allied health occupations. The committee
could not make quantitative predictions of personnel shortages and sur-
pluses because of the usual uncertainties of occupational projections and
the absence of necessary data elements. Yet if employers, higher education
planners, federal and state ofﬁcials, and others had soundly based projec-
tions, decision making might be improved.

The federal government in its role as monitor of the nation’s economic
activity has a responsibility to monitor the health care work force and to
inform participants in the health care labor market and public policymakers
of trends and developments. The work of the Bureau of Health Professions,

4 ALLIED HEALTH SERVICES

the Bureau of Labor Statistics, and the Center for Education Statistics is
to be commended and should be built upon. To improve the data on allied
health ﬁelds, the committee recommends that the secretary of health and
human services convene an interagency task force composed of repre-
sentatives from the Bureau of Labor Statistics, the Center for Education
Statistics, and other agencies that collect relevant data on the allied health
work force. This task force should work toward increasing the amount
and improving the quality of data needed to inform public policy decision
makers, health care managers, unions, prospective students, and aca-
demic institutions about the allied health occupations.

To help implement this recommendation and others that require federal
action, the committee recommends that the Department of Health and
Human Services maintain an organizational focal point on allied health
personnel to implement the grant programs recommended in this report,
to coordinate the recommended work of the interagency data task force,
and to facilitate communication among state legislative committees and
the federal government.

Factors That Affect the Demand for and Supply of
Allied Health Personnel

A ﬁrst step in understanding or projecting the future of the allied health
occupations, either as a group or for individual ﬁelds, is to understand the
ways in which certain forces operate in the environment to drive demand
and supply. Early action in response to these forces can forestall the need
for more radical corrections at a later date.

THE CURRENT EMPLOYMENT SITUATION

Available data did not enable the committee to develop a reliable estimate
of whether the supply of practitioners in the various allied health ﬁelds
was in reasonable balance with demand. However, during the course of
the study, the committee was in contact with people who observe various
portions of the allied health labor market. These educators and employers
expressed increasing concern about the availability of students and prac—
titioners. Educators generally reported that their graduates found jobs
easily; employers, on the other hand, reported increasing difﬁculties in
ﬁlling vacancies. There are, of course, variations among ﬁelds and localities.
The committee heard reports of shortage most frequently for physical
therapists. For other ﬁelds there were reports of less severe shortages or
of hiring difﬁculties that were related to local conditions, to changes in
licensure, or to a particular employer’s problems. The volatility of the labor
market could be easily seen: at the beginning of the study, some educators

EXECUTIVE SUMMARY 5

were concerned about an oversupply of clinical laboratory personnel; 18
months later concerns centered on employers’ growing difﬁculties in hiring
trained clinical laboratory personnel.

It is clear that changes in the health care system have caused and are
still causing shifts in employment patterns. Prospective payment and other
efforts to control hospital utilization caused initial reductions in hospital
employment for some allied health ﬁelds. For other ﬁelds the rate of
increase in hospital employment slowed; still others showed a substantial
increase. The growth of out—of—hospital care has accelerated, creating new
sites for the employment of allied health personnel. Whether in the long
run these changes translate into a substantial number of additional jobs or
merely a shift in the location of employment is an important question—
not only for projecting allied health personnel demand but also for the
way personnel are educated to practice in new settings. Moreover, allied
health practitioners working in these new settings also raise issues for reg-
ulators who are concerned with the quality of care and for traditional
employers who must now compete for personnel with employers who can
sometimes offer more attractive salaries and working conditions.

The committee used the best data available to make assessments of how
the forces that drive demand and supply will affect allied health labor
markets. Its intention is to alert decision makers to the kinds and magni-
tudes of market adjustments that they should expect and encourage to
sustain a long-term balance between allied health personnel demand and
supply.

Markets eventually adjust to change. Projected imbalances in demand
and supply do not necessarily mean that shortages or surpluses will occur.
Rather, they signal that employers and potential employees must and prob—
ably will make adjustments. Only rarely do markets fail to accommodate
changes in demand and supply. Yet there are inherent time lags and
inefﬁciencies in the process that can be lessened by public and private
interventions.

THE FUTURE EMPLOYMENT SITUATION

Barring major economic or health care ﬁnancing contractions, the growth
in the number of jobs for allied health workers will substantially exceed
the nation’s average rate of growth for all jobs. Unless some existing trends
are moderated, the flow of practitioners into the work force through grad—
uation from education programs will be, at best, stable.

For some ﬁelds, such as physical therapy, radiologic technology, medical
record services, and occupational therapy, the committee foresees a need
for decision makers to improve the working of the market so that severe

6 ALLIED HEALTH SERVICES

imbalances in demand and supply may be prevented. Employers are al-
ready concerned about difﬁculties in hiring in some of these ﬁelds, and
there are signs that health care providers are beginning to search for ways
to accommodate new realities. Because some of the accommodations are
expensive and difﬁcult to accomplish, the committee is concerned that
inaction may cause crises that could be avoided—health care services could
be disrupted because providers of care are not available.

For some other ﬁelds, such as 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, in both
of these ﬁelds, there are unresolved issues concerning the level of personnel
that will be allowed to perform certain jobs. The way these issues are
resolved could determine whether major demand and supply imbalances
will occur.

Demand and supply for speech—language pathologists, audiologists, re-
spiratory therapists, and dietitians are expected to be sufﬁciently well bal-
anced 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 maintain a state of equilibrium
over time. Nevertheless, for these and other allied health occupations,
changes in a number of factors that affect the health care environment
could cause disequilibrium. These factors include health care ﬁnancing
policies, technology change, decisions about education programs, and reg-
ulatory policies. Those concerned with respiratory therapy, for example,
must closely monitor an educational capacity that has proved volatile, as
well as changes in home care reimbursement policy.

Our conclusions about the future outlook for allied health personnel
refer to the long term and are national in scope. For all ﬁelds, there are
likely to be periods of greater and lesser imbalance between now and the
year 2000, as well as local variations in demand and supply. The objective
of policy is to make the process of adjustment less painful and costly. A
decline in the quality of care, interruptions or reductions of service, and
the curtailment of investment in new technologies and organizational forms
(e.g., home or outpatient care) that might improve the efﬁciency of health
care delivery are all possible by-products of personnel shortages. The de-
cision to intervene in the labor market is made through the political process
and reﬂects society’s willingness—0r unwillingness—to tolerate painful dis—
locations. In many industries, such dislocations are viewed as normal and
acceptable. Yet public policy actions have demonstrated that health care is
viewed differently. The committee investigated how educators, employers,
regulators, and government can facilitate the smooth working of the
market.

EXECUTIVE SUMMARY 7

EDUCATION

The function of the education sector in determining the size and com-
position of the work force is clear. Unless educators, in league with em-
ployers and professional associations, are successful at fostering an interest
in allied health careers among qualiﬁed prospective students, both the
education programs and the allied health work force will be weakened.

Demographic studies show that the proportion of the US. population
18 to 23 years old has been declining since the beginning of this decade
and will continue to decline through the mid-19905. This shrinkage of the
college-age population will make it increasingly difﬁcult for allied health
programs to attract qualiﬁed applicants. In addition, other attractive op-
portunities compete for that population’s attention. This competition sug-
gests that greater attention will have to be paid to maintaining allied health’s
share of the traditional pool of students and that less traditional sources
of students (e.g., minorities, older persons, and career changers) should
be tapped.

Academic allied health programs must overcome the perception, and to
some extent, the reality, that they are excessively costly and that their faculty
do not make sufﬁcient scholarly contributions to their institutions. Modest
but strategic actions by the federal government can help education pro-
grams deal with these problems and compete more effectively for acade-
mia’s limited resources. The committee recommends federal actions that
would provide a signal to those who carry most of the responsibility for
allied health education—states, education administrators, and employers—
that these programs must not be undervalued.

The problems of allied health educators can be analyzed in terms of the
recruitment of students, the ﬁnancing of programs, and the supply of
qualiﬁed faculty.

Faced with increased competition for students, educational institutions
must become creative in their approaches to recruitment. Alliances must
be forged with organizations that are also interested in recruiting allied
health personnel. The committee therefore recommends that educational
institutions, in close collaboration with employers and professional as-
sociations, organize for the recruitment of students. Students should be
sought in less traditional applicant pools—among minorities, older stu-
dents, career changers, those already employed in health care, men (for
fields in which they are underrepresented), and individuals with hand-
icapping conditions.

One way to create access to a larger pool of students is to allow entry
into education through multiple routes.

Alternative pathways to entry-level practice should be encouraged
whenever feasible. State higher education coordinating authorities and

8 ALLIED HEALTH SERVICES

legislative committees should insist that educational institutions facilitate
mobility between community college and baccalaureate programs.

The recruitment of minority students is a particular concern for several
reasons: minorities represent a relatively untapped source of manpower;
their representation in the population as a whole is increasing; and minority
professionals are more likely to serve underserved populations.

There have been a number of attempts to recruit and retain minorities
in the health professions. The lessons from successful models suggest that
interventions must occur early in a student’s life and continue through the
academic career. The major source of support from the federal govern-
ment has come from the Health Careers Opportunity Program.

The committee recommends that minority recruitment efforts begin
before high school. Academic institutions must offer academic support
services for the retention of students and seek to promote educational
mobility. To succeed over the long term, these efforts must be made
integral to the mission of educational institutions.

The committee endorses the objectives of the Health Careers Oppor-
tunity Program and believes that funding levels must be maintained at
least at current levels.

Allied health programs are vulnerable to closure because they appear to
lag behind other programs in contributing to the academic standing and
ﬁnancial health of the institution in which they are located. The committee
made a number of recommendations directed toward several aspects of
this problem. The overall strategy it recommends is to put allied health
programs on a more equal footing with other academic programs.

To enhance the stability of allied health education, national organi-
zations such as the American Society of Allied Health Professions should
investigate models in which academic institutions have succeeded in
broadening their financial base through such mechanisms as faculty prac-
tice plans, extension courses, and industry relationships. These national
organizations should also hold workshops to help institutions implement
the models and disseminate information.

Until credible alternative approaches are developed, the federal gov-
ernment and other third-party payers should maintain current reim-
bursement levels and mechanisms of support for clinical education.

The committee found that in some ﬁelds, shortages were inhibiting the
expansion of educational capacity despite strong student and employer
demand. More generally, deans believe that allied health faculty are be-
coming disassociated from clinical practice to the detriment of students’
preparation for the workplace. This is due in part to the academic reward
system, which does not place a high value on patient care. Attention to
faculty skills, however, should not come at the expense of progress in
solidifying the research underpinnings that guide everyday practice.

EXEC UTIVE S UMMAR Y 9

The federal government and the states should fund faculty develop-
ment grants in allied health fields, especially when faculty availability
and lack of clinical expertise inhibit the production of entry-level work-
ers.

A cadre of researchers and academic leaders is needed to advance the
scientiﬁc base of allied health practice. To accomplish this goal, insti-
tutions with strong research commitments should consider developing
programs that identify and nurture talented individuals. The committee
recommends the development of a federal research fellowship program
to support these activities.

Private foundations should support centers for allied health studies
and policy development. These university-based centers would provide
a critical mass of researchers and resources to advance technology as-
sessment, health services research, and human resource utilization.

Institutions offering allied health academic programs should reward
and encourage faculty clinical competence. Clinical practice that sustains
this competence should be made a requirement and a criterion for pro-
motion.

HEALTH CARE INSTITUTIONS

Health care employers directly generate demand for allied health work—
ers and indirectly affect supply by the conditions of employment they offer.

The committee reviewed the available literature to determine the sorts
of activities that employers could undertake to enhance the supply of allied
health workers by making a career in an allied health ﬁeld more attractive
to people Choosing an occupation and by increasing retention rates. Few
studies of allied health were found. Most of the relevant work is from
nursing, where intermittent shortages have focused interest on what it takes
to reduce nurse turnover. The literature makes it clear that employers are
able to affect work force entrance and exit rates. Even a small increase in
tenure has a signiﬁcant impact on the size of the work force.

The committee recommends that employers strive to increase the sup-
ply of allied health practitioners by attracting people into allied health
occupations and prolonging their attachment to their fields. Some ways
to do this include increasing compensation and developing mechanisms
for retention. Employers should also look to new labor pools that include
men, minorities, career changers, and individuals with handicapping
conditions.

Despite the reluctance of employers to raise pay in a cost-contained
environment, if shortages occur, compensation will increase as administra-
tors are compelled to try to attract new entrants into allied health profes-

10 ALLIED HEALTH SERVICES

sions. This increased compensation will make allied health personnel a
more costly resource.

The committee found little evidence of the strategic planning and re-
search that could help employers effectively use allied health practitioners
and at the same time preserve the quality of care, working within regulatory
constraints and avoiding professional resistance. Nowhere is there a sub-
stantial body of research to improve the effectiveness of allied health prac-
titioners’ activities.

Available data indicate that in many allied health occupations entry-level
pay is currently competitive with other comparable occupations, but allied
health salaries over the life of a career are so compressed that there is no
incentive to remain in the occupation. The effective use of human resources
will necessitate compensation incentives to increase tenure; it will also re-
quire that work be organized in a way that uses the greater experience of
the more expensive members of the work force.

The committee recommends that health care providers and adminis-
trators seek innovative ways to channel limited allied health resources
toward activities of proven beneﬁt to consumers. Agencies such as the
National Center for Health Services Research and the Health Care Fi-
nancing Administration should sponsor research and technology assess-
ment to ensure that allied health services are effective and that they are
organized efﬁciently. Association; of employers, unions, accrediting
agencies, and professional associations should assist in disseminating
research findings and providing technical assistance in their implemen-
tation.

Health care managers will not succeed if they must act alone in these
efforts. Educational institutions and the professional associations, which
provide the basis for practitioners’ goals and aspirations as well as technical
knowledge and skills, must also participate. Educators, employers, and
professional associations must engage in a regular exchange of ideas and
experimentation.

Chief executive ofﬁcers, human resource directors, and other health
care administrators must develop methods for the effective utilization of
the existing supply of allied health personnel. Such methods must grow
out of experimentation with new ways of organizing work efﬁciently and
the distribution of labor among skill levels, alway ensuring that the
quality of care is not compromised. I

Employers and educators must forge a relationship to ensure that grad-
uates are not frustrated by unrealistic expectations about what their work
will entail and employers do not ignore the need for career paths and
professional stimulation. To be successful, this effort requires that em—
ployers and educators try to understand each other’s concerns and con-
straints and the pressures exerted by a changing environment.

EXECUTIVE SUi MARY 11

Health care administrators and academic administrators must engage
in constructive exchanges to improve the congruence of employment and
education. These exchanges, which should take place at the state and
local levels, will be enhanced by the participation of educators who are
also leaders of the professional associations.

To facilitate this interaction, the committee recommends that state
legislatures establish special bodies whose primary purpose would be to
address state and local issues 'in the education and employment of allied
health personnel.

LICENSURE, CERTIFICATION, AND ACCREDITATION

The committee took a broad View of the charge from Congress and
examined the full spectrum of allied health personnel regulation, including
state licensure of individuals and health facilities, certification of individuals
by private organizations, the imposition of standards by third-party payers,
and voluntary accreditation of education programs.

Collectively, these regulatory measures affect the size and characteristics
of the allied health work force. They affect the functioning of the labor
market for allied health workers by deﬁning who may enter the various
fields, by determining who has what degree of control over health care
services and dollars, and by constraining the range of staffing options
available to employers. They provide identity and legitimacy to newly
emerging occupations and their members.

Occupational licensure is of particular concern to the committee on sev-
eral grounds. As the most restrictive type of regulation, it grants exclusive
control over some health services to one type of worker. The committee
concluded that licensure is costly and cumbersome and that its effectiveness
in protecting the public has not been conclusively demonstrated. The ef-
forts being made in a number of states to reform the regulatory process
are encouraging, particularly the evolution of “sunrise” criteria to evaluate
the need for regulating new occupations, which the committee endorses.
Increasing the public’s participation in the regulatory process is also a
positive development. The committee recommends that states strengthen
the accountability and broaden the public base of their regulatory statutes
and procedures. In the near term, the committee suggests that licensing
boards draw at least half of their membership from outside the licensed
occupation; members should be drawn from the public as well as from
a variety of areas of expertise such as health administration, economics,
consumer affairs, education, and health services research.

Flexibility in licensure statutes should be maintained to the greatest
extent possible without undue risk of harm to the public. This may mean,

12 ALLIED HEALTH SERVICES

for instance, allowing multiple paths to licensure or overlapping scopes
of practice for some licensed occupations.

In light of concerns about the future availability of adequate numbers
of allied health personnel and in light of the rapid changes in health care
delivery, licensure appears to be inconsistent with the ﬂexibility that will
be needed in the years to come. The committee believes that states should
try to ﬁnd alternatives to licensure. Professional groups should work toward
strong title certiﬁcation, devoting their efforts to convincing the public and
the industry of the credential’s value—much as certiﬁed public accountants
have done in their sphere.

The committee recommends statutory certiﬁcation for ﬁelds in which
the state determines there is a need for regulation because this form of
regulation offers most of the benefits of licensure with fewer of its costs.
Medicare and other third-party payers should accept state title certiﬁ-
cation as a prerequisite for reimbursement eligibility. Such certiﬁcation
can and should be based on examinations and any other eligibility criteria
the states may establish.

The committee was concerned that jurisdictional struggles among health
occupations over scopes of practice and over referral and supervision re—
quirements were conducted without a body of research literature or the
informed judgments of knowledgeable, disinterested parties to guide those
decisions. Without such information, there is considerable risk that deci-
sions will be made on purely political and economic grounds. It was the
committee’s view that the federal government should take an active part
in developing the necessary evidence for use by authorities responsible for
these decisions.

The Bureau of Health Professions (or other future focal points for
allied health personnel in the Department of Health and Human Services)
should sponsor a body with members drawn from allied health and other
health professions and from the health and social science research com-
munities to assess objectively the evidence bearing on “turf” issues. This
body, in consultation with other experts and interested parties, should
consider issues of risk, cost, quality, and access. It should draw on avail-
able scientiﬁc evidence and identify topics on which research is needed.

LONG-TERM CARE

The committee chose to devote special attention to long-term care for a
number of reasons. The aging of the population and the need for long-
term care for the elderly are major forces in future demand for allied
health services. Despite broad concern about the needs of the elderly, there
is no certainty that the current ﬁnancing systems will enable providers to

EXECUTIVE SUMMARY l3

satisfy those needs. Furthermore, because long—term care requires both
therapeutic and social support services, it affords an opportunity to examine
the issues that surround the interaction of allied health practitioners with
other professionals such as nurses, as well as with workers having relatively
minimal formal education—an important group of workers on which the
committee wished to focus attention.

Allied health practitioners relate differently to their clients and to other
health care providers in each of the three long-term settings that were
studied—nursing homes, home care, and rehabilitation facilities. In nurs-
ing homes, minimally trained nurse’s aides are often the primary care givers
with the most frequent patient contact. Recent congressional and Health
Care Financing Administration actions to increase aide training are a step
in the right direction. Yet, in the future, aides will require an even higher
level of training to link them more effectively to nursing and allied health
personnel in the delivery of hands—on care.

In recognition of the fact that the greatest amount of direct patient
contact and care in long-term care settings and programs is provided by
personnel at the aide level, the federal government and other responsible
governmental agencies should require education and training to increase
the knowledge and skills of these personnel. Demonstration projects should
be funded to encourage joint efforts by educators and employers in cre-
ating career paths for aides.

Some types of organizations that provide long-term care, such as home
health agencies and nursing homes, must coordinate a wide array of services
that are needed by fragile clients with multiple disorders. If this coordi-
nation is mishandled, the result may be fragmented care, sometimes du-
plicative efforts, and often less than optimal use of each service. Collaborative
team work by the care providers can improve the quality of care by helping
team members better understand each other’s roles; it also helps to ensure
appropriate, coordinated care and might even reduce staff turnover by
increasing each team member’s involvement in the job.

Therefore, the committee recommends that, because the problems as-
sociated with chronic illness do not fall within the boundaries of any
single discipline, administrators and care coordinators in long-term care
settings develop effective means to ensure that all personnel involved in
patient care work closely together to meet patient needs.

More generally, allied health workers in all long-term care settings need
special preparation to care for patients with chronic illness, to understand
the psychological aspects of aging, and to confront disability, death, and
dying. Therefore, the committee recommends that all allied health ed-
ucation and training programs include substantive content and practical
clinical experience in the care of the chronically ill and aged.

I4 ALLIED HEALTH SERVICES

COLLABORATIVE ACTION

Taken as a whole, the committee’s recommendations are designed not
merely to advance the role of allied health occupations but also to preserve
the ability of the health care system to confront the problems of the next
decade. In drafting its recommendations the committee was cognizant that
no one entity in the public or private sector now has the power or re-
sponsibility to determine whether allied health education and practice will
adequately respond to the challenge of changing patterns of illness and
care requirements. Ultimately, collaborative action will be required. None
of the committee’s recommendations is self-implementing. Each requires
a principal party to convince others to join in their efforts or to accede to
alterations in traditional ways of operating, whether in educating students,
delivering services, or supporting professional interests.

1

 

What Does “Allied Health” Mean?

COMPUTERIZED SEARCH of the nation’s newspapers for October 1987

found the term allied health in two stories. During the same time, there
were 443 references to nursing and more than 500 references to physicians.
The individual fields that normally fall under the heading of allied health
fared only somewhat better. Physical therapists were mentioned in 21 ar-
ticles, occupational therapists in 8, dental hygienists in 7, and medical tech-
nologists in 3. The scarcity of such references reﬂects a lack of public
awareness of what allied health practitioners do and the fact that the term
means little or nothing to the public at large. Even in the health care
community there is considerable confusion about which ﬁelds fall under
the rubric of allied health. Many of the people who deliver allied health
services or educate its practitioners have long been dissatisfied with the
term. Yet this dissatisfaction has led neither to a replacement nor to a
commonly accepted deﬁnition. The only consensus is a distaste for the
predecessor term paramedlcal. Appendix C includes a sample list of job titles
and allied health ﬁelds that might be included in the broadest deﬁnitions
of allied health.

In the late 19705, a National Commission on Allied Health Education,
supported by a grant from the W. K. Kellogg Foundation to the American
Society of Allied Health Professionals, tried to formulate a consensus def-
inition. The commission’s struggle with the concept is reﬂected in its def-
inition, which follows a six-page discussion: “. . . all health personnel working
toward the common goal of providing the best possible service in patient
care and health promotion” (National Commission on Allied Health Ed—
ucation, 1980). This deﬁnition does not draw boundaries that exclude

15

16 ALLIED HEALTH SERVICES

groups of health care providers, nor does it describe commonalities of task
or education that deﬁne the ﬁelds to be included. Rather, the commission
chose to focus thematically on “alliances that need to be built” and “the
collaborative approach to providing health services” as part of a team———an
approach that has value when the overall purpose of the deﬁnition is to
bind together a disparate group of practitioners.

The deﬁnition offered by the American Medical Association’s Committee
on Allied Health Education and Accreditation (CAHEA), a body that ac—
credits nearly 3,000 educational programs, suggests the sensitivities in—
volved in designating the ﬁelds that allied health comprises. CAHEA (1987)
deﬁnes allied health practitioners as:

. . . a large cluster of health care related professions and personnel whose functions
include assisting, facilitating, or complementing the work of physicians and other
specialists in the health care system, and who choose to be identiﬁed as allied health
personnel.

Deﬁnitions of allied health vary due to its changing nature and to the differing
perspectives of those who attempt its deﬁnition and because certain medically
related but traditionally parallel or independent occupations prefer identities in-
dependent of allied health: nursing, podiatry, pharmacy, clinical psychology, etc.
Other occupations may or may not regard themselves as allied health, depending
upon their varying circumstances, e.g., nutritionists, speech—language pathologists,
audiologists, public health specialists, licensed practical nurses, medical research
assistants, etc.

CAHEA’s discussion emphasizes that there are two approaches to de-
ﬁning allied health: the ﬁrst describes groups or characteristics of groups
that fall within certain ill-deﬁned boundaries; the second relies on excluding
groups.

In its 1979 A Report on Allied Health Personnel (US. Department of Health,
Education, and Welfare), the federal government adopted the latter view.
It attempted to winnow out from 3.5 million health care workers those in
ﬁelds that came under the federal purview of allied health. Its criteria
excluded health care workers who (1) were treated separately by legislation
other than the allied health authorization; (2) had general (rather than
health-speciﬁc) expertise that could be applicable to other industries; and
(3) performed functions that required little or no formal training in health
care subject matter.

Thus, in addition to physicians, nurses, dentists, optometrists, podiatrists,
pharmacists, veterinarians, and other independent health practitioners, the
authors of the report excluded

0 professional public health personnel;
0 biomedical research personnel;
0 natural and social scientists working in the health ﬁeld;

WHAT DOES “ALLIED HEALTH” MEAN? l7

0 nursing auxiliaries; and
O occupations requiring no formal training (US. Department of Health,
Education, and Welfare, 1979).

Despite the continuing debate about deﬁnition and boundaries, some
groups of practitioners have come together and unequivocally call them-
selves allied health personnel. The federal programs that supported allied
health education provided the impetus for the aggregation of such groups
as occupational therapists, clinical laboratory technologists, and dental hy-
gienists. The groups coalesced in three major spheres: (1) academic insti-
tutions under schools of allied health, to beneﬁt from multidisciplinary
interaction and educational efﬁciency; (2) health services settings, for rea-
sons of personnel administration; and (3) the professional associations, to
attempt to inﬂuence policy, collect information, and publish scholarly pa-
pers\on issues of interest across the ﬁelds.

This coalescing is by no means complete; there are many academic pro-
grams that lie outside allied health schools, numerous health facilities that,
operationally, do not recognize allied health as a useful grouping of oc-
cupational categories, and strong allied health professional associations that
act independently of each other in the policy arena. Nevertheless, the
reasons for the diverse groups to come together under the umbrella rubric
allied health remain valid.

This committee chose not to engage in the search for a deﬁnition. The
beneﬁts of making the term allied health more precise are less clear than
the beneﬁts of continued evolution. The changing nature of health care
makes some practices and practitioners obsolete at the same time it opens
up opportunities to form new groups. It is more important for pragmatism
to continue to prevail and for old and new groups to draw what beneﬁts
they can from belonging to allied health than it is to have an accurate
description of common characteristics that deﬁne the group.

Lacking a satisfying deﬁnition of allied health, many groups have tried
to impose order with a variety of classiﬁcation schemes. They have been
classiﬁed according to their departmental afﬁliation into such categories
as dental, dietary, emergency, diagnostic, and therapeutic. One study em-
phasized certain features that cut across different types of work. It rec-
ommended classiﬁcation according to patient, laboratory, administration,
and community-oriented groupings (Bureau of Health Manpower, 1967).
A poll of professional associations arrived at three “clusters” according to
job function: (1) primary care workers (including medical, dental, and
nursing personnel); (2) health promotion, rehabilitation, and administra-
tion personnel; (3) and test-oriented workers (National Commission on
Allied Health Education, 1980). Clearly, there is no “correct” taxonomy:
different classiﬁcation schemes emphasize different aspects of allied health

18 ALLIED HEALTH SERVICES

jobs and personnel. The different emphases can be used to serve different
purposes. Rather than rely on a single deﬁnition or scheme throughout
the study, the committee preferred to emphasize the following character-
istics of allied health ﬁelds. Each paragraph highlights important policy-
related characteristics and helps to explain how the ﬁelds are affected in
different ways by changes in the health care environment.

1. Level of autonomy Some allied health ﬁelds have a history of practice
without direct supervision; others are struggling for a measure of inde—
pendence. Individuals in many ﬁelds can work only as employees in su-
pervised settings. Practitioners who can attract their own patients can reap
the ﬁnancial rewards of the public’s interest in and willingness to pay for
their services. However, independent autonomous practice is not possible
unless health care payers are willing to reimburse allied health practitioners
for their services and unless the practitioners are free of regulation that
requires onsite supervision by a physician.

2. Dependence on technology In a health care system that frequently adopts
new machines or techniques, individuals who work with only one machine
may lose their jobs as new technologies are developed and brought into
use. Those workers who become broadly involved in one or more tech-
nologies are less vulnerable to obsolescence. Those involved with techno-
logical innovations that are coming into widespread use should beneﬁt
from a strong demand for their services.

3. Substitutability of personnel Allied health occupations vary as to whether
their “turf ’ is well marked and protected. If workers from two occupations
or two levels of the same occupation can perform the same functions, the
workers who are paid more or who are more specialized may be displaced.
If more highly trained workers are willing to work for the same wage as
those with less education, the lower level practitioner may be displaced.
For employers, the ability to substitute one type or level of personnel for
another may be helpful when the supply of one type of worker is limited.

4. Flexibility in location of employment Those who can work in a variety
of settings are less vulnerable in a job market that responds to altered
ﬁnancing incentives by shifting the location of care or by limiting the
amount of care provided in some settings.

5. Degree of regulation If a ﬁeld is highly regulated (i.e., its practitioners
are licensed by the state, required to register with a government agency,
or their titles are protected by certiﬁcation), employers are constrained
from hiring anyone but workers from that ﬁeld to perform a function.
These workers are protected from substitution by other personnel. The
supply of workers is likely to decrease if the requirements for entry into
the ﬁeld are raised.

6. Inclusion in futility accreditation or certiﬁcation standards To receive ac-
creditation or certiﬁcation, a health care facility may be required to employ

WHAT DOES “ALLIED HEALTH” MEAN? 19

practitioners in certain ﬁelds. If so, the demand for these workers will
respond to changes in the number of these facilities.

Throughout this study a major challenge for the committee was both to
capture the diversity of allied health occupations and to devise speciﬁc yet
encompassing recommendations for those who must make policy decisions
affecting the role of allied health practitioners in the health care system.
Toward this end the committee chose to focus on 10 allied health ﬁelds.
It used the following criteria in selecting the ﬁelds: (1) each ﬁeld should
be large and well known; (2) collectively, they should span the spectrum
of autonomy; and (3) collectively, they should include practitioners who
work in a variety of health care settings. However, wherever it has appeared
suitable for this report, the committee also chose to draw on information
about other allied health occupations that was provided to it.

The ﬁelds the committee chose to focus on are clinical laboratory tech-
nology, dental hygiene, dietetic services, emergency medical services, med-
ical record services, occupational therapy, physical therapy, radiologic
technology, respiratory therapy, and speech—language pathology and au—
diology.

The ﬁnal chapter of this report includes an examination of the role of
nursing aides in long-term care. Nursing aides often are not included
among categorizations of allied health personnel. They are highlighted
here, however, because of the crucial role they play in patient care in many
long-term care facilities, a role that makes their relationship with allied
health personnel very important.

In addition, the discussion of aides in the ﬁnal chapter focuses attention
on some groups that are discussed less thoroughly in the remainder of the
report than the committee might have preferred. These lower level prac-
titioners, often called technicians or aides, are frequently trained on the
job or educated in short vocational programs or 1-year certiﬁcate programs.
Analysis of the present and future supply of allied health practitioners
depends heavily on data from educational institutions that are not available
for lower level personnel. Moreover, the jobs and tasks of lower level
personnel generally are not clearly delineated, and even their job titles can
be confusing. The committee therefore was unable to evaluate trends in
demand or the forces that determine the demand for and supply of lower
level practitioners.

The observations made by a commission assembled by the American
Dietetic Association (ADA) (1985) to examine their profession help explain
why studies of lower level personnel are difﬁcult to conduct. During World
War II, high school vocational programs, adult education programs, and
hospital education programs began to train dietetic support personnel called
food service supervisors. To this array of training sites were added cor-
respondence courses developed by ADA in the late 19505. When it became

20 ALLIED HEALTH SERVICES

apparent that a more highly educated support person was needed, the
dietetic technician position was created; these personnel were trained in
food service management, nutrition care, or as generalists. The food su-
pervisor title was subsequently changed to that of dietetic assistant. Al-
though in 1972 ADA published program essentials for both categories and
began the formal review and approval of educational programs, in the
same year a study commission determined that the tasks of the two ﬁelds
needed deﬁnition (American Dietetic Assocation, 1972). A decade later an
attempt to determine the numbers of dietetic support personnel failed
(American Dietetic Association, 1985). During that attempt, many problems
were found. For example, workers identiﬁed as dietetic technicians were
actually graduates of dietetic assistant or other programs. At the same time,
the title dietetic assistant was deemed to be inappropriate because often
these practitioners did not assist but rather managed. In 1983 their title
was changed to that of dietary manager. In the same year, partly because
it could no longer differentiate the roles of the two types of support per-
sonnel, ADA withdrew from the review and approval program of dietetic
assistants’ education. A membership association of dietetic technicians and
assistant managers took over this function.

In sum, dietary support personnel are both formally and informally
trained, their roles are ill-deﬁned, and their titles are in a continually
evolving state. Moreover, ADA also notes that dieticians often use support
personnel for clerical rather than dietary tasks.

The committee is aware that aides, technicians, and assistants play an
important, if sometimes ill-deﬁned, role in the nation’s health care system.
By focusing on nursing aides in the ﬁnal chapter of this report, we hope
to give the reader an impression of the vital nature of their work.

This chapter brieﬂy introduces each of the 10 allied health ﬁelds covered
in the report and outlines their evolution.* It also traces the development
of two ﬁelds—perfusion and cardiovascular technology—to see whether
developing ﬁelds tend to follow the same general pathways as the estab-
lished occupations. Appendix D offers the committee’s best estimates of
the number of workers currently in each of the 10 ﬁelds.

CLINICAL LABORATORY TECHNOLOGY

Clinical laboratory personnel perform a wide array of tests that are used
to help physicians prevent, detect, diagnose, and treat diseases. The gen-
eralist medical technologist is the most widely recognized practitioner in

*The description of the allied health ﬁelds was drawn in large part from a paper
prepared for the committee by Edmund T. McTernan (1987). Where appropriate, other
sources are referenced. For McTernan’s bibliography, see Appendix H.

WHAT DOES “ALLIED HEALTH” MEAN? 2 1

this ﬁeld and the one on which this report focuses, but there are many
specialities within the ﬁeld including blood bank technology (the prepa-
ration of blood for transfusion), cytotechnology (the study of body cells),
hematology (the study of blood cells), histology (the study of human tissues),
microbiology (the study of microorganisms), and clinical chemistry (the
analysis of body ﬂuids).

Practitioners fall into two broad categories: (1) baccalaureate—prepared
technologists and (2) associate degree- and certiﬁcate-prepared technicians.
Technologists perform complex analyses, make ﬁne-line discriminations,
and correct errors. They are able to recognize the interdependency of tests
and have some knowledge of physiological conditions that could affect test
results. They use this knowledge to conﬁrm those results and develop data
that aid physicians in determining the presence, extent, and, as far as
possible, causes of disease (CAHEA, 1987). Technicians perform routine
tests under the supervision or direction of pathologists or other physicians,
scientists, or experienced medical technologists. Associate degree-prepared
technicians may discriminate between similar items, correct errors by using
preset strategies, and monitor quality control programs within predeter-
mined parameters.

The ﬁrst clinical laboratory in the United States was established in 1875
at the University of Michigan hospital. Soon thereafter, laboratories were
established at other hospitals. Physicians specializing in pathology were
responsible for these laboratories, but because the work was often routine,
they soon hired nonphysician assistants. By 1900 there were approximately
100 technicians in laboratories around the country. The demand for lab—
oratory personnel greatly increased with the expansion of the health care
system during World War I. By 1920 there were 3,500 laboratory tech-
nicians in the United States, half of whom were women. A census taken 2
years later revealed that 3,035 hospitals had established clinical laboratories.

All early laboratory technicians were trained for their role by the pa-
thologists for whom they worked. In 1922 a training program was estab-
lished at the University of Minnesota. Today, a bachelor’s degree with a
major in medical technology, biology, or chemistry is the standard prereq-
uisite for an entry-level job as a medical technologist. Medical technology
programs (offered by colleges, universities, and hospitals) are based on
considerable course work in the physical sciences and mathematics—often
closely resembling the premedical curriculum—and at least 1 year of clinical
training. Hospital programs are usually afﬁliated with universities that
grant the academic degree. Technologists can also become recognized as
such through a federal certifying exam. In 1972 the federal government
established its own testing program to certify laboratory workers and make
them eligible to provide reimbursable services in Medicare and Medicaid
programs. Successful candidates are recognized for Medicare and Medicaid

22 ALLIED HEALTH SERVICES

purposes as clinical laboratory technologists. Medical technicians may be
graduates of 2—year programs in community or junior colleges or of 4-year
colleges that offer associate degrees; alternatively, they may be graduates
of a 1-year certiﬁcate program sponsored by a hospital or vocational school.

Five states require that medical technologists or technicians be licensed.
Other states require that the practitioner register with the designated legal
authority. Although professional association certiﬁcation is voluntary, it is
frequently a prerequisite for clinical laboratory jobs and often necessary
for professional advancement. Agencies that certify personnel include the
Board of Registry of the American Society of Clinical Pathologists, the
American Medical Technologists, and the National Certiﬁcation Agency
for Medical Laboratory Personnel and the International Society of Clinical
Laboratory Technologists.

Concerns over the quality of laboratory testing have surfaced recently,
and during its public hearing, the committee heard a number of suggested
approaches to address these concerns. One approach proposed by some
leaders in the ﬁeld is the introduction of licensure to ensure that laboratory
personnel have received the requisite training. They also support efforts
to deﬁne the scope of practice for each level of personnel. Others in the
ﬁeld do not believe that licensure ensures quality, nor do they wish edu-
cational credentials to be the primary tool for differentiating competencies.

According to the American Society of Clinical Pathologists (1987), there
were 172,214 technologists and 37,271 technicians registered as of February
1987. The U.S. Bureau of Labor Statistics (BLS) estimates that there were
approximately 239,000 jobs in 1986, of which 63 percent were in hospitals.
It should be kept in mind that not all people doing work described as that
of a clinical laboratory technologist 0r technician are certiﬁed. Individuals
with expertise in a science ﬁeld, as well as persons without a health-related
or science-based education, are often hired and given on-the-job training
to perform clinical laboratory functions. This is particularly true in settings
that are not regulated by the federal government—for example, physician
ofﬁce laboratories.

Clinical laboratory technologists and technicians are most often women;
only about 25 percent of the work force are men. The more highly trained
practitioners, graduates of 4-year colleges, are a little older than the grad-
uates of 2-year colleges. Of the group of 4-year college graduates, 37
percent are under 35 years old; 53 percent of the 2-year college graduate
group fall into that age bracket (Bureau of Health Professions, 1984).

DENTAL HYGIENISTS

Dental hygienists, working under the supervision of dentists, remove
stains and deposits from patients’ teeth, take and develop x-ray ﬁlms, apply

WHAT DOES “ALLIED HEALTH” MEAN? 23

ﬂuoride, and make impressions of teeth for study models. They also instruct
patients in oral hygiene. In states with less restrictive practice acts, dental
hygienists also apply sealants to teeth, perform periodontal therapy, and
administer local anesthesia. Most hygienists work in private dental ofﬁces,
although other employment sites include public health agencies, school
systems, hospitals, and business ﬁrms. Hygienists should not be confused
with dental assistants, who work with the dentist handing instruments,
preparing for procedures, and performing other tasks that assist the den-
tist’s work.

Dentists ﬁrst began expressing interest in prophylactic care as an adjunct
to restorative dentistry in the mid-18005. By the turn of the century, many
had developed protocols for preventive care and were delivering it to their
patients. However, these services were time-consuming for the dentist and
hence costly for the patient. In 1910 the Ohio College of Dental Surgery
instituted a training course for the “dental nurse and assistant.” The 1-year
program graduated a single class before a coalition of Ohio dentists suc—
ceeded in closing it down.

Three years later, a Connecticut dentist, Dr. Alfred Fones, convinced
his local school board to fund a program to train dental hygienists who
would work in the school system giving prophylactic care to children. Fones
envisioned dental hygienists working in private dental offices as well, but
he placed greater emphasis on the public schools.

The profession first gained legal status in Connecticut, which amended
its dental practice act in 1915 to permit hygienists to practice under a
dentist’s supervision. The following year a court ruling in New York held
that no existing New York law prevented dental hygienists from practicing.
Subsequently, the American Dental Association endorsed dental hygiene
legislation, and by 1951 hygienists were licensed throughout the United
States.

It was not until 1947 that the American Dental Association and the
American Dental Hygienists’ Association developed the approved require-
ments for accreditation of dental hygiene programs. These requirements
have been modiﬁed several times; to receive approval today, a program
must have both liberal arts and science content, and didactic and clinical
instruction. Most programs grant an associate degree but often require
more than 2 academic years to complete. A smaller number of programs
take 4 years and culminate in a baccalaureate. The dental hygiene field
reﬂects some of the ambivalence about education seen in the nursing
profession: although 4-year programs undoubtedly have more academic
content and presumably prepare graduates for additional career roles,
there is only one level of dental hygiene license. All licensed hygienists,
regardless of the degrees they hold, are permitted to perform the same
range of dental services.

24 ALLIED HEALTH SERVICES

Of the issues facing dental hygienists today, autonomy is the most press-
ing. Licensure is effectively in the hands of dentists rather than dental
hygienists: in all states, hygienists are licensed by a licensing board that is
composed primarily of dentists. At present, there is a strong movement
within the profession to gain greater self-determination. One goal is to
abolish state laws requiring that licensed hygienists work exclusively under
dental supervision. In Colorado, hygienists have already won the right to
practice independently, although the move has not been made without
controversy. The American Dental Association filed suit against the state
demanding the reinstitution of the requirement that patients be referred
to hygienists only by licensed dentists. The suit was dismissed, but the
association is currently appealing the decision.

Dental hygienists are generally young women: only 1 percent of the work
force are men, and only 10 percent are more than 44 years old. In 1984
only 13 percent earned more than $25,000 per year (American Dental
Hygienists’ Association, 1987).

DIETETIC SERVICES

According to the ADA’s 1972 study commission, a dietician is a “trans-
lator of the science of nutrition into the skill of furnishing optimal nutrition
to people.” Although all dietitians share a common interest in the science
of food and its effect on the body, they work in many different roles—as
administrators, educators, researchers, and clinicians. Some supervise large-
scale meal planning at companies and school cafeterias; others assess the
nutritional needs of hospitalized patients and implement specialized diets;
still others advise individuals and groups on sound dietary practices. Die-
ticians are also involved in hyperalimentation and the clinical frontiers of
parenteral and enteral nutrition.

The term dietician was first coined at the 1899 Lake Placid Conference
on Home Economics, but the roots of the profession extend back two
decades earlier to cooking schools in Boston, New York, and Philadelphia.
One early practitioner, Sarah Tyson Rorer, held classes on nutrition for
physicians and nurses before the turn of the century; she later edited a
section of an American Medical Association publication called “The Dietetic
Gazette.”

Like many other allied health professions, dietetics expanded during
World War I. In England, 40 percent of the 2.5 million men screened for
military service were found to be physically unﬁt, most for nutritional
reasons. Good nutrition and food conservation for the public and better
health care for the troops, especially those who were sick and wounded,
were of great concern at the time, both in the United States and in England.
Biomedical advances also helped to stimulate the ﬂedgling profession.

WHAT DOES “ALLIED HEALTH” MEAN? 25

From its inception in 1918, ADA was active in accreditation, listing hos-
pitals that offered reputable dietary internships. By 1927 the association
had adopted a standard course for dieticians, the first of several steps
toward ADA-sponsored accreditation of educational programs. In 1969
the association established a registry of dietitians. To qualify for registration
today requires graduation from an accredited college or university, com-
pletion of certain course and experiential components, and passing a na-
tional registration exam. In addition, dieticians must fulﬁll continuing
education requirements to maintain certiﬁcation. The term nutritionist, which
was previously reserved for people working in research, is gaining popu-
larity with clinical practitioners. It has been proposed that “nutrition” be
added to ADA’s name, but this change has not been approved by the
membership. As of the summer of 1987, ADA members continued to call
themselves dietitians.

There are several issues of major concern to dieticians today. First, the
profession is seeking to extend and strengthen state licensure. Currently,
14 states license dieticians, and a number of others are considering such
laws. Second, because there is a slow but steady trend in the ﬁeld toward
private practice, dieticians are interested in obtaining third-party reim-
bursement for their services. Finally, ADA is exploring how the ﬁeld might
be divided into subﬁelds. Like several other allied health professions, the
sum total of knowledge in the field has grown to the point where special-
ization seems inevitable. Those dieticians who today consider themselves
to be specialists have most often become so through concentrated work in
specific health care settings. Thus, it is generally on-the-job training rather
than formal education that makes them specialists. At present, an ADA
committee is developing speciality boards and defining speciality areas.

The best estimate of the size of the dietetics work force comes from
ADA which reported 44,570 active members at the end of 1987 (American
Dietetic Association, 1987). BLS estimates that there were approximately
40,000 dieticians’ jobs in 1986, 37 percent of which were in hospitals (Bu-
reau of Labor Statistics, 1987).

The 1984 Study Commission on Dietetics described the “typical” ADA
member as a young, college-educated white woman. According to the Com—
mission, slightly more than 63 percent of ADA members were under 40
years old, 99 percent had a bachelor’s degree, 97 percent were women,
and 87 percent were white (American Dietetic Association, 1985). Little
has changed since then. In 1986 fewer than 1 in 10 ADA members was a
man. Eighty-six percent of technicians were white, compared with 88 per-
cent of active dieticians. Sixty-three percent of active dietician members
were under 41 years old, while technicians were a little younger (71 percent
under 41). Forty percent of active dietician members have advanced de-
grees, and another 10 percent are working toward such degrees. For 70

26 ALLIED HEALTH SERVICES

percent of technicians the associate degree was the highest degree earned
(Bryk, 1987).

EMERGENCY MEDICAL SERVICES

Emergency medical technicians (EMTs), formerly called ambulance at-
tendants, care for people at the scene of emergencies and transport them
to hospitals or other health care institutions. EMTs (basic, intermediate,
and paramedic) determine the nature and extent of victims’ medical and
trauma—related emergencies and provide limited care. Depending on their
level of training and on state regulations, EMTs may provide such care as
opening and maintaining airways, controlling bleeding, immobilizing frac-
tures, and administering certain drugs.

The ﬁrst ambulance service was started during the Civil War in an effort
to decrease mortality rates on the battleﬁeld. By the late 1800s, several
hospital-based ambulance services were operating in urban areas such as
New York City and Cincinnati; smaller communities began introducing
volunteer services in the mid-1940s. The main function of these early
operations was transport. Ambulance personnel, who were often morticians
and volunteers, were not trained in the delivery of emergency care.

Early in 1960 the US Department of Health, Education, and Welfare
(DHEW; now the Department of Health and Human Services) established
an emergency medical services program. The program was moved to the
Department of Transportation (DOT) with the passage of the Highway
Safety Act in 1966, which required states that were receiving federal high-
way construction funds to develop emergency services or lose 10 percent
of those funds. The act recommended that ambulances be equipped with
speciﬁc lifesaving equipment and be managed by at least two people trained
in emergency care.

A 1966 report by the National Research Council summarized practices
and deﬁciencies of various levels of emergency care and gave speciﬁc rec-
ommendations for a national effort to improve emergency services. The
report was the ﬁrst to identify the need to develop the EMT as an occu-
pational category with formal education. A common basic training course
was the ﬁrst step to increase the professionalism of ambulance personnel.
The most widely used training course was developed by DOT in 1969. In
1970 the National Registry of EMTs was organized to unify EMT educa-
tion, examinations, and certiﬁcation nationally.

In September 1970, under a contract funded jointly by DHEW and DOT,
the National Academy of Sciences Subcommittee on Ambulance Service
developed guidelines for an advanced training program to train basic-level
EMTs (known as EMT—As) to become EMT-paramedics (EMT—PS). This
development marked the beginning of the paramedic role in the EMS
system. EMT-PS are qualiﬁed to carry out advanced procedures (e.g., start-

WHAT DOES “ALLIED HEALTH” MEAN? 27

ing intravenous infusions, tracheal intubation, and deﬁbrillation) under
remote medical supervision.

EMTs who did not ﬁt into either of the two previously mentioned cat-
egories—~that is, those who were more advanced than EMT-As but not as
highly trained as EMT-Ps—were not recognized by certiﬁcation, although
their numbers increased steadily. In 1980 the National Registry and DOT
determined that a standardized educational program and certiﬁcation of
intermediate—level personnel (EMT-Is) were needed and in 1981 began
testing and providing certiﬁcation for these technicians. EMT-Is receive
the basic EMT training and portions of the EMT—P curriculum.

Today, the 110-hour national EMT basic training course is offered by
police, ﬁre, and health departments and as a nondegree course in medical
schools, colleges, and universities. Since 1982 paramedic training programs
have been eligible for voluntary accreditation by CAHEA. All 50 states
have some kind of certiﬁcation procedure. In 24 states, registration with
the National Registry is required at some or all levels of certiﬁcation. Fifteen
other states offer a choice of their own certiﬁcation examination or the
National Registry examination. All states require EMT—Ps to be certiﬁed
by an agency of the state.

Career (paid) EMTs are employed by private ambulance services, hos-
pitals, and municipal police and ﬁre departments. Volunteer EMTs typi-
cally work for volunteer rescue squads and ﬁre departments.

Emergency medical services continue to be dominated by volunteer per-
sonnel (although they are becoming increasingly difﬁcult to recruit) who
are not always able to devote time to attaining and maintaining the training
for advanced certiﬁcation. Volunteer EMTs are overwhelmingly EMT—As.
The mix of levels of training varies by locality, however. In rural areas, for
example, where the EMT work force typically is composed of volunteers,
any EMT-PS are likely to be volunteers. On the other hand, in many urban
localities, emergency medical services are entirely staffed by career per—
sonnel.

EMT-Ps are being used increasingly in hospital emergency departments
to provide emergency medical service and to supplement nursing staff.
EMT-As are sometimes hired but typically perform only limited roles. In
at least two states, Pennsylvania and Kansas, nursing groups have formally
protested the practice of using EMTs to perform nursing functions in
emergency departments. In Maryland, nursing leaders have called for the
development of a job description for emergency department EMTs.

MEDICAL RECORD SERVICES

Medical record personnel develop, implement, and manage medical in-
formation systems. They are responsible for keeping track of the records

28 ALLIED HEALTH SERVICES

of an institution’s patients, compiling statistics required by federal and state
agencies, and assisting the medical staff in evaluating patient care. In ad-
dition, medical record personnel work closely with the institution’s ﬁnance
department to monitor spending patterns. Some medical record personnel
code information, evaluate record completeness and accuracy, and enter
information into computers. Three out of four jobs in this ﬁeld are located
in hospitals; other major employment sites include health maintenance
organizations (HMOs), nursing homes, and medical group practices. In-
surance, accounting, and law ﬁrms that specialize in health matters also
employ medical record personnel, as do companies that develop and mar-
ket medical record information systems.

The ﬁrst medical record administrator, Grace Whiting Meyers, was ap-
pointed by Massachusetts General Hospital in 1897 to organize the patient
care records that had been accumulating for 80 years. Other hospitals in
the Boston area and elsewhere soon followed suit, hiring medical record
personnel or librarians, as they came to be called. By 1912 a group had
organized to share information and ideas. Four years later the group adopted
a name—the Club of Record Clerks. Over the next 50 years, the club
evolved into a national organization now known as the American Medical
Record Association (AMRA).

The American Association of Medical Record Librarians, AMRA’s pre-
cursor, did not establish ofﬁcial standards for training programs until 1934.
In 1942, at the group’s request, the American Medical Association assumed
the responsibility of approving educational programs for medical record
personnel. Yet the number of approved schools grew slowly. To increase
the pool of qualiﬁed persons in the ﬁeld and provide recognition to those
workers who could not qualify as registered librarians, standards were
promulgated in 1953 for programs to train a lower level worker, the medical
record technician.

At ﬁrst, most training programs for both librarians and technicians were
based in hospitals. But by the 1960s the ﬁeld’s leaders were convinced that
professional record librarians needed a broad liberal arts education. By
1970 all approved programs for medical record librarians granted a bach-
elor’s degree and were based in colleges and universities. Technician pro—
grams were also shifted: today, medical record technicians generally hold
an associate degree from a junior college.

As health care institutions have grown in size, the role of a medical record
librarian has evolved from that of a clerk to that of an information systems
manager. Today, the head of a medical record team often organizes a
large-scale information service, trains and supervises staff, and devises means
of evaluating patient care. Reﬂecting this shift in responsibilities, the med-
ical record librarian title was changed in 1970 to medical record admin-
istrator. Medical record education programs have gradually adopted course

WHAT DOES “ALLIED HEALTH” MEAN? 29

work in areas such as business management and data processing. In ad-
dition, administrators may now specialize in subflelds that include quality
assurance, information management, computerization of information, and
tumor registry. To become a registered medical record administrator, can-
didates must have graduated from an accredited baccalaureate program
and pass a registry examination.

Because registration in this ﬁeld is voluntary and because medical record
departments use on-the-job trained personnel for some lower level jobs, it
is hard to determine the size and composition of the current medical record
work force. In 1987 AMRA reported 8,240 registered medical record
administrators and 14,690 accredited record technicians. BLS estimated
that there were nearly 40,000 technician jobs existed in 1986. AMRA es-
timates that 98 percent of its membership are women, and approximately
95 percent are white (R. Finnegan, American Medical Association, personal
communication, 1987).

OCCUPATIONAL THERAPY

Occupational therapists direct their patients in activities that are designed
to help them learn the skills necessary to perform daily tasks, diminish or
correct pathology, and promote and maintain health. Therapists work in
many different settings including rehabilitative and psychiatric hospitals,
school systems, nursing homes, and home health agencies. The nature of
their work varies according to the setting. Therapists working in mental
hospitals, for instance, typically provide activities that help mentally ill and
retarded people learn to cope with daily stresses and manage their work
and leisure time more efficiently. In rehabilitative hospitals, therapists may
orient patients to the use of equipment (e.g., wheelchairs and splints) or
custom—design special equipment; they may also recommend changes in
patients’ work or home environments to facilitate their functioning. Because
the field is so extensive, occupational therapists tend to work with speciﬁc
age groups or disabilities. The profession can be most readily divided into
those who work with mentally disabled people and those who work with
physically disabled people. Three out of ﬁve therapists work with people
with physical disabilities—some work only with the elderly, whereas others
work exclusively with children.

The roots of occupational therapy (OT) go back at least 200 years to
French physician Philippe Pine], who found that mental patients given
menial tasks to perform improved more quickly than those patients who
were idle. In the United States at the end of the eighteenth century, phy-
sician Benjamin Rush also advocated work as a treatment for his mentally
ill patients at Philadelphia’s Pennsylvania Hospital. In 1906 the first training
course for occupational therapists was established in Boston.

30 ALLIED HEALTH SERVICES

World War I spurred the growth of OT and expanded its scope of
practice to include physical as well as mental rehabilitation. Initially, four
OT reconstruction aides were recruited for service in European-based
American army hospitals. In 1917, it was decided that 200 others were
needed to “furnish forms of occupations to convalescents in long illnesses
and to give the patients the therapeutic beneﬁt of activity.” Three crash
programs were subsequently established that by 1921 had trained hundreds
of OT aides.

The National Society for the Promotion of Occupational Therapy was
established in 1917; the association changed its name 3 years later to the
American Occupational Therapy Association (AOTA), the name it bears
today. In 1923, the ﬁeld received a major boost when the Federal Industrial
Rehabilitation Act required that every general hospital treating victims of
industrial accidents provide occupational therapy. In addition, during that
year, AOTA first established minimum standards for training programs:
these called for a 12-month professional training program open to high
school graduates. Ten years later, AOTA and the American Medical As-
sociation began collaborating on accreditation for OT programs.

Since then, the ﬁeld’s body of knowledge has expanded considerably,
and educational requirements have been strengthened. Today, there are
two levels of education in the ﬁeld—technical and professional—and there
is no upward mobility through experience alone. Occupational therapy
education programs receive accreditation through CAHEA. Technical ed-
ucation programs grant an associate degree and prepare individuals for
certiﬁcation as an occupational therapy assistant (COTA). Professional pro-
grams are offered at three levels—baccalaureate, postbaccalaureate certif-
icate, and master’s degree—and prepare a person to become credentialed
as a registered occupational therapist (OTR). In addition to such training,
occupational therapists now specialize in one of several subﬁelds: geron-
tology, developmental disabilities, training in activities of daily living, pros-
thetics training and construction of splints, and the rehabilitation of people
with spinal cord injuries and neurological disorders.

As of 1987, 34 states plus the District of Columbia and Puerto Rico had
OT licensure laws. All of the laws specify that the AOTA certiﬁcation exam
be used as the licensing exam. Licensure also requires a degree or certiﬁcate
from an accredited educational program.

Although the roots of occupational and physical therapy are similar,
autonomy for occupational therapists has been slower to develop than
autonomy for physical therapists. Reimbursement for OT inpatient services
is covered by third-party payers; until recent changes in Medicare, reim-
bursement for outpatient and in-home services has been more erratic. Still,
.a growing number of therapists are in private practice. Some work in
consulting ﬁrms or multispeciality group practices, while others are solo

WHAT DOES “ALLIED HEALTH" MEAN? 31

practitioners. Typically, their patients are referred by physicians or other
health professionals.

To leaders in the ﬁeld, a major concern continues to be OT’s difﬁculty
in meeting the demand for qualiﬁed practitioners. Demand has grown
considerably over the past several decades, but experts also attribute the
shortage of practitioners to the profession’s failure to attract sufﬁcient
numbers of students. One recruitment impediment may be the unwilling-
ness of many people to make their careers in psychiatric settings. In ad-
dition, laymen often confuse OT with physical therapy (PT), and the more
visible and autonomous PT may be more attractive to potential students.

The best estimate of the size of the occupational therapy work force is
AOTA’s list of registered active members, who numbered 27,300 at the
end of 1987. Occupational therapists are most often women (95 percent)
with a median age of 32. Most work full time (70 percent), and 20 percent
are self—employed. Twelve percent have master’s degrees (a bachelor’s de—
gree is the minimum educational requirement). The mean income reported
in 1986 was approximately $26,500 (AOTA, 1986).

In 1986 AOTA also counted 7,909 COTAs (certiﬁed occupational ther—
apy assistants) among its members. Their characteristics in some ways were
similar to those of the therapists. Their median age and the proportions
that were women and worked full time were almost identical to those of
the therapists. However, their education and earnings differed. Among
the COTAs, 74 percent had associate degrees, and 29 percent had diplomas
or certiﬁcates; their average earnings were $16,182 (AOTA, 1986).

PHYSICAL THERAPY

Physical therapists plan and administer treatment to relieve pain, im-
prove functional mobility, maintain cardiopulmonary functioning, and limit
the disability of people suffering from a disabling injury or disease. Ther-
apeutic activities include exercises for improving endurance, strength, co—
ordination, and range of motion; electrical stimulation to activate paralyzed
muscles; instruction in the use of aids such as crutches or canes; and
massage and electrotherapy to alleviate pain and promote healing in soft
tissues.

Physical therapists work in a variety of employment settings. In 1986
one-third of the available jobs were in hospitals. Other major employers
include rehabilitation facilities, home health agencies, nursing homes, HMOs,
school systems, and clinics. In addition, almost 20 percent of physical ther-
apists are in private practice. Some work alone or in a group practice;
others provide care on a contract basis to an institution (e.g., a hospital or
nursing home).

32 ALLIED HEALTH SERVICES

Modern physical therapy was born during World War I when the country
was suddenly faced with the need to rehabilitate large numbers of wounded
soldiers. In 1917 the surgeon general of the army initiated an intensive,
short-term program that trained 800 “reconstruction aides” (all women) in
physical therapy. Reconstruction aides were civilian employees of the US.
Army Medical Corps and typically worked in army hospitals. As soldiers
were discharged after the war, the need for reconstruction aides grew in
the civilian sector. In addition, the army continued to employ aides to work
with hospitalized veterans.

In 1920 the American Women’s Physical Therapeutic Association was
formed by reconstruction aides who had served in the war. Reconstruction
aides were considered charter members; membership requirements for
others seeking to join the association included graduation from “recognized
schools of massage and therapeutic exercise with some knowledge of either
electrotherapy or hydrotherapy.” By the end of 1921, the new association
had 245 members. It became the current American Physical Therapy As—
sociation (APTA).

World War II brought a sudden increase in the demand for therapists
to treat injured servicemen, a demand that was met largely through the
rapid establishment of federally funded, accelerated programs to prepare
college graduates from fields such as physical education for practice as
therapists. These accelerated programs were often operated in parallel with
existing 4-year university degree or certiﬁcate programs. They were dis-
continued at the end of the war, but the many graduates they supplied
were generally regarded as highly competent, and this temporary system
provided impressive evidence of the ability of educational programs to
respond to a sudden change in demand for personnel. During the 19405
and early 1950s a series of severe poliomyelitis epidemics created another
rapid rise in demand for therapists. This time, however, both demand and
supply were strongly inﬂuenced by the private sector. Massive donations
to the National Foundation for Infantile Paralysis (the March of Dimes)
were used to employ therapists, set up treatment centers, and subsidize
therapy for a large number of patients. Concurrently, the foundation in—
vested heavily in the education of therapists by (l) underwriting salaries
for many new faculty positions to permit existing schools to expand en-
rollments, (2) funding an intensive student recruitment and scholarship
program that drew many new people into the ﬁeld, and (3) supporting the
development of graduate programs for faculty training.

The dramatic reduction in the number of new polio patients following
development of the Salk and Sabin vaccines in the early 19505 had only a
brief dampening effect on the demand for physical therapists. Growing
interest in the vocational rehabilitation of young adults and the expansion
of rehabilitation services to previously underserved groups of patients with

WHAT DOES “ALLIED HEALTH” MEAN? 33

a wide variety of movement disorders soon absorbed the personnel pre-
viously needed for the care of acute polio patients.

Today, all states require that practicing physical therapists be licensed,
and applicants must hold a degree from an APTA-accredited program
prior to taking the licensing exam. (APTA directly accredits educational
programs independent of CAHEA.) Since 1960 there have been three
educational avenues to entry-level jobs as physical therapists: (1) baccalau-
reate programs, (2) certiﬁcate programs for people who already hold a
bachelor’s degree in another ﬁeld, and (3) 2-year master’s programs. In
1979 APTA announced its intention to elevate the entry-level requirement
for the ﬁeld to a master’s degree—a mandate that encountered vigorous
opposition, especially from the American Hospital Association, deans of
allied health programs, and certain higher education associations. As a
result, the mandate has been softened to encourage rather than require a
general movement toward the master’s degree as the entry-level credential.

In 1967 an assistant-level position was created so that physical therapists
could delegate more routine tasks and treat greater numbers of patients.
Currently, there are approximately 17,000 practicing physical therapy as-
Sistants.

Physical therapists have more autonomy than most allied health practi—
tioners. Many are in private practice, and some states allow patients direct
access to physical therapy services, which eases the way into independent
practice for therapists. Thirty-eight states now permit physical therapists
to evaluate patients without medical referral; 11 of these states also permit
the treatment of patients so evaluated. Legislation on direct access is pend-
ing in about a dozen other states.

As the scope of practice in physical therapy has expanded to include
services as diverse as pulmonary therapy for critically ill patients in intensive
care units, developmental assessment of high-risk newborn infants, home
care for elderly stroke and arthritis patients, and industrial consulting to
reduce low back injuries, specialization has become a feature of the careers
of many therapists. In 1978 APTA established a board for certiﬁcation of
advanced clinical competence that currently oversees the examination and
certiﬁcation of clinical specialists by speciality boards in six ﬁelds: cardi-
opulmonary, clinical electrophysiology, neurological, orthopedic, pediatric,
and sports physical therapy. Thirty universities now offer postprofessional
graduate programs (including nine doctoral-level programs) for advanced
professional study by experienced therapists.

APTA estimates that the number of licensed physical therapists in 1986
was nearly 66,000. Physical therapists are most often women; in 1987 men
constituted 25.4 percent of the work force, a little down from 28.8 percent
in 1978. On average, women therapists are slightly younger (35 years old)
than men (38 years old). The proportion of minority therapists remained

34 ALLIED HEALTH SERVICES

between 4 and 5 percent in the past decade. The 15 percent of the work
force who worked full time for themselves were the highest earners, gross-
ing nearly $73,000 on average in 1986, compared with approximately
$32,000 for the 67 percent who were full-time salaried employees. The
educational attainments of physical therapists have increased during the
past 10 years. The percentage with master’s degrees has increased from
15.2 percent to 21.5 percent since 1978. The percentage with a doctoral
degree increased slightly from 1.1 percent to 1.4 percent (APTA, 1987).

RADIOLOGIC TECHNOLOGY

Radiologic services as an allied health ﬁeld began with the diagnostic use
of x rays and the applications of these and other types of ionizing radiation
for therapeutic purposes. Originally, radiologic services were provided al-
most exclusively by radiologists (physicians) and their technical assistants
or x-ray technicians (now called radiographers); in recent decades, how-
ever, radiologic services have expanded considerably. New professions have
emerged with medical and technological advances. New applications of
radioactive tracers led to the birth of nuclear medicine technology; the
invention of therapeutic x-ray equipment for treating cancer resulted in
the ﬁeld of radiation therapy technology; and the development of ultra-
sound imaging systems has created a new category of radiologic personnel,
the diagnostic medical sonographer.

Radiologic technologists and technicians (including radiographers, ra-
diation therapy technologists, nuclear medicine technologists, and diag-
nostic medical sonographers) held approximately 125,000 jobs in 1986.
About two of every three jobs were located in hospitals. Other employment
sites included clinics, laboratories, and doctors’ ofﬁces.

Twenty-ﬁve years after the discovery of x rays in 1895 by Wilhelm
Roentgen, 13 x-ray technicians gathered in Chicago and formed the Amer-
ican Association of Radiological Technicians (now called the American
Society of Radiologic Technologists). In 1920 a committee of physicians
was appointed by the Radiological Society of North America to consider
standards for the training of x-ray technicians. Two years later the Ra-
diological Society of North America and the American Roentgen Ray So-
ciety organized the American Registry of X-ray Technicians (now called
the American Registry of Radiologic Technologists). The registry was con-
trolled by physicians until 1961 when the composition of the registry board
was changed to include technologists. Initially, all training in radiologic
technology was done on the job. Gradually, however, hospitals organized
schools for technicians, and a program evolved that comprised a year of
classwork followed by a year of clinical training. In 1933 the ﬁrst three
programs were recognized by the registry. Today, CAHEA accredits more
than 1,000 formal training programs in the ﬁeld.

WHAT DOES “ALLIED HEALTH” MEAN? 35

Radiologic technology education changed after World War II, partly as
a result of the GI. Bill. Large numbers of returning veterans were inter—
ested in careers in the expanding health care ﬁeld and, at the same time,
wished to pursue formal education under the GI. Bill. Many administrators
of 2—year colleges recognized this new market and established 2-year radio-
logic technology programs that granted an associate degree. This devel-
opment came on the heels of a growing movement within the ﬁeld to
extend the duration of training programs.

At present, there are formal training programs in radiography, sonog-
raphy, radiation therapy technology, and nuclear medicine technology.
They range from 1 to 4 years and grant a certiﬁcate, an associate degree,
or a baccalaureate. Two-year programs are the most common. Some 1-
year programs attract health care professionals who are interested in chang—
ing ﬁelds—most often, respiratory therapists, registered nurses, and med—
ical technologists. Certiﬁcate programs also attract radiographers who want
to specialize in ultrasound, radiation therapy, or nuclear medicine. Cur-
rently, 4-year programs are designed primarily for people interested in
teaching or supervisory positions.

There appears to be a trend in the ﬁeld toward programs of longer
duration based in institutions of higher education. Because some educators
feel that advances in technology have made it difﬁcult to train students
adequately in 2 years, a number of associate degree programs are exper-
imenting with a third year. Some leaders in the ﬁeld feel that the slight
difference between a 3-year associate degree program and a 4-year bach-
elor’s program will push the ﬁeld toward making the baccalaureate degree
the educational standard for entry-level jobs.

As of summer 1987, only ﬁve states—New York, New Jersey, Florida,
California, and Kentucky—had licensure laws for radiologic technologists.
In 1984 Congress passed the Jennings Randolph Bill requiring states either
to establish minimal educational standards for radiologic technologists or
adopt extant federal requirements, which call for voluntary compliance.
Almost all states have opted for voluntary compliance.

The radiologic technology work force is one of the largest among the
allied health ﬁelds. The Bureau of Health Professions estimates that there
were 143,000 radiologic health service workers in 1986, of which approx-
imately two-thirds were women and half were under 30 years of age (Bu-
reau of Health Professions, 1988).

RESPIRATORY THERAPY

Respiratory therapists provide an array of services that ranges from
emergency care for stroke, drowning, heart failure, and shock to providing
temporary relief to patients with emphysema or asthma. They often treat
patients who have undergone surgery because anesthesia depresses breath-

36 ALLIED HEALTH SERVICES

ing and respiratory therapy may be prescribed to prevent the development
of respiratory illnesses. The majority of respiratory therapists works in
hospital settings, although increasing numbers are being employed by nurs-
ing facilities and home health agencies.

Since the 18005, doctors have prescribed oxygen therapy for individuals
with cardiopulmonary problems, and until recently the task of actually
administering treatment fell to attending nurses. After World War 11,
however, much of the equipment for administering oxygen became so
sophisticated and expensive that administrators began assigning respiratory
care tasks to orderlies who became known as oxygen orderlies. These first
respiratory therapists, although usually employees of nursing departments,
frequently developed direct relationships with physicians and often came
to know more about gas therapy than their immediate supervisors.

The ﬁeld’s ﬁrst professional organization, the Inhalational Therapy As-
sociation, was formed in Chicago in 1946. Now, several decades later, the
organization is national in scope and is known as the American Association
for Respiratory Care (AARC).

As the ﬁeld and its body of medical knowledge evolved, the range of
tasks performed by respiratory therapists widened to include both the
mundane and the highly complex. As a result, in the late 19605, leaders
in the ﬁeld promoted the idea of developing an entry-level position so that
respiratory therapists could be relieved of their more routine tasks. In 1969
the ﬁrst inhalation therapy technicians were certiﬁed.

Today, training is offered at the postsecondary level in colleges and
universities, medical schools, trade schools, and hospitals. To be accredited
by CAHEA, programs for respiratory therapists must be of at least 2 years’
duration and lead to an associate or baccalaureate degree. Technician pro—
grams usually last 1 year. Certiﬁcation is voluntary and available through
the National Board for Respiratory Care. As of June 1987, respiratory care
personnel were licensed in 18 states, and licensure bills had been introduced
in 10 others.

Members of the ﬁeld currently are concerned about issues relating to
competition with other health care workers. They are alarmed by incursions
into the ﬁeld that have been made by other health care workers, especially
nurses, who in the early years performed the functions (or the precursors
of the functions) that are usually handled by respiratory therapists today.
To halt these incursions and protect the quality of respiratory services,
therapists are seeking licensure in all 50 states. It should be noted that
AARC, unlike many other allied health organizations, is not currently striv-
ing to achieve greater independence from physicians for its membership.
The AARC leadership anticipates that respiratory personnel will continue
to work under the direction of physicians.

WHAT DOES “ALLIED HEALTH" MEAN? 37

BLS estimates that there were more than 56,000 respiratory therapy jobs
in 1986, the majority of them in hospitals. AARC suggests, however, that
administrative positions were excluded in the BLS count. Two-thirds of
respiratory therapists are under 30 years of age, and—unusual for an allied
health ﬁeld—almost 40 percent are men.

SPEECH—LANGUAGE PATHOLOGY
AND AUDIOLOGY SERVICES

Audiologists and speech—language pathologists held approximately 45,000
jobs in 1986. Slightly more than half of these positions were in elementary
and secondary schools, universities, and colleges. Hospitals, nursing homes,
speech—language and hearing centers, and private physicians provided
most of the remaining jobs. Unlike most other allied health professions,
the speech—language—hearing profession does not function exclusively or
even principally in the medical world. Moreover, the care provided by these
professionals was not previously supplied by physicians. The development
of these fields took place in the educational sector. Early in this century,
educators became interested in introducing speech correction services into
the public schools. The Chicago school system was the first to offer these
services, hiring 10 speech correction teachers in 1910. Within 6 years,
Detroit, Boston, New York, and San Francisco had followed Chicago’s lead
and were also employing speech correctionists. University education of
individuals interested in speech correction was initiated in the United States
around 1915 at the University of Wisconsin.

Most early speech correctionists saw themselves as specialized teachers
of elocution and belonged to a large organization known as the National
Association of Teachers of Speech (NATS). In 1925 a group of speech
correctionists decided to form a semiautonomous organization under the
auspices of NATS to serve their professional interests, and the American
Academy of Speech Correction (AASC) was born. Among the goals of the
fledgling organization was raising “existing standards of practice among
workers in the ﬁeld of speech correction” and securing “public recognition
of the practice of speech correction as an organized profession” (Paden,
1970)

During the next several years, the academy grew, but with growth came
dissatisfaction over its close connection with NATS. The traditional dates
of the annual NATS meeting apparently were not convenient for a number
of AASC members, many of whom felt that AASC should be afﬁliated
with groups in the medical world rather than with NATS. After 25 years,
AASC separated from NATS; today, the organization is known as the
American Speech—Language—Hearing Association (ASHA).

38 ALLIED HEALTH SERVICES

A master’s degree in speech—language pathology or audiology is the
basic credential in this profession, although there are numerous programs
in communications sciences and disorders at the baccalaureate level. Of
the approximately 235 colleges and universities offering master’s degree
or doctoral programs in speech—language pathology and audiology, about
two-thirds are accredited by ASHA. Course work at accredited schools
includes basic communication processes, the study of speech—language
pathology or hearing disorders or both, and related areas such as the
psychological aspects of communication. Most persons with a master’s de-
gree pursue the Certiﬁcate of Clinical Competence (CCC), which is offered
by ASHA in either speech—language pathology or audiology. To earn the
CCC, the individual must hold a master’s degree or its equivalent, complete
a supervised clinical fellowship year, and pass ASHA’s written exam.

Thirty-six states require that individuals providing speech—language pa-
thology and audiology services hold licenses if they practice privately in
clinics or in other nonschool settings. Medicare, Medicaid, and other third-
party payers pay for the services of licensed practitioners. In states that do
not have licensure laws, Medicare and Medicaid require that speech—lan-
guage pathologists and audiologists meet the educational and clinical ex-
perience requirements for the CCC or be in the process of accumulating
the necessary clinical experience.

Increasing numbers of individuals within the ﬁeld are becoming inde-
pendent private practitioners. This trend, while fairly new, is rapidly grow-
ing. Like the leaders of other increasingly autonomous allied health
professions, authorities in speech—language pathology and audiology are
seeking to ensure that standards of practice remain high.

ASHA estimates that approximately 86,700 speech—language patholo-
gists and audiologists are active in the work force (Shewan, 1988). Ap-
proximately 15 percent of the practitioners certiﬁed by ASHA are audiologists,
and most of the remainder are speech—language pathologists; about 2
percent of speech—language—hearing practitioners are certiﬁed in both
speech—language pathology and audiology (ASHA, 1986). In 1987 au-
diologists earned slightly more than speech—language pathologists. The
median annual salary in 1987 for ASHA member audiologists was $28,000
compared with $25,000 for speech—language pathologists (ASHA, 1988).
The speech—language pathology work force is overwhelmingly white and
female (approximately 95 percent and 89 percent, respectively, in 1988).

NEW ALLIED HEALTH FIELDS

The committee recognizes that the 10 ﬁelds selected for this study rep-
resent established, traditional allied health professions. Yet the changing
pattern of health care delivery has tended to spawn new allied health

WHAT DOES “ALLIED HEALTH” MEAN? 39

ﬁelds—ﬁelds that develop as changes occur in the health care system and
as technology develops or expands. The committee looked brieﬂy at two
ﬁelds —perfusion and cardiovascular technology—that recently have come
to be recognized as allied health occupations to see if developing ﬁelds
tend to follow the same general pathways as those of the established oc—
cupations. These two ﬁelds developed from core elements they once shared
with respiratory therapy. Early academic programs covered heart and lung
procedures; as technologies developed, practitioners specialized in one or
another area, and separate ﬁelds and occupations evolved.

Perfusion

Perfusionists began in the mid-19505 as pump technicians for heart—
lung machines—equipment that was designed to withdraw blood from a
patient’s body, cleanse and oxygenate it, and pump it back into the body.
These technicians moved with the equipment from experimental labora-
tories into clinical settings as assistants to surgeons and anesthesiologists.
Trainees were often drawn from other disciplines, including nursing and
respiratory therapy, and were trained on the job until the mid~1970s.

By the mid-19605, perfusionists saw the need to develop a system for
certifying practitioners and to establish a minimal base of knowledge for
the profession. They formed the American Society of Extra-Corporeal
Technology (AmSECT) to organize the profession and provide information
and professional services to its members; in 1968 AmSECT began a pro-
gram of certiﬁcation for perfusionists. The American Board of Cardio-
vascular Perfusion was established in 1974 to conduct certiﬁcation as an
independent activity. In 1977 CAHEA recognized perfusion as an allied
health profession, and the way was paved for establishing accredited schools
for training.

In the years following the move to certiﬁcation for perfusionists and
prior to the establishment of accredited training programs, technicians
trained on the job were allowed to sit for the certiﬁcation exam. Since 1981,
however, when school programs became available, certiﬁcation require-
ments have changed, and no one may sit for the exam without having
graduated from an accredited program.

Perfusionists work under the general supervision of a physician. Whereas
they used to work only with heart—lung machines, perfusionists now man-
age highly technical patient monitoring devices in the operating room. In
addition, they are no longer limited only to assisting during heart bypass
procedures; now, perfusionists also assist during organ transplants. The
profession is striving to expand its expertise and not limit its focus to one
technology; in pursuit of these goals, it is expanding its scope to include
managing patient monitoring devices that have not been claimed by another

40 ALLIED HEALTH SERVICES

allied health ﬁeld. Perfusion thus is taking a course not dissimilar to that
of the older, established allied health professions.

Cardiovascular Technology

The ﬁeld of cardiovascular technology involves the diagnosis and treat-
ment of patients with cardiac and peripheral vascular disease. It is seg-
mented into three distinct areas: (1) invasive cardiology, (2) noninvasive
cardiology, and (3) noninvasive peripheral vascular study. As each of these
areas developed and as changing technology led to their divergence, tech-
nicians in each area were trained to conduct the requisite tests and pro-
cedures. The three groups have remained together for the purpose of
designing an educational program.

Cardiovascular technology has been recognized by CAHEA as an allied
health profession since December 1981. Cardiovascular technologists and
technicians specialize in one or more of the three‘areas. Program accred-
itation criteria have been developed, but thus far there are no accredited
programs for training cardiovascular technicians. Several programs are
expected to be available by the fall of 1988.

The range of skills and training required by cardiovascular technologists
and technicians is broad. Within the area of noninvasive cardiology, for
example, procedures rangefrom electrocardiography (EKG), which may
be taught in a few hours, to echocardiography, an ultrasound technique
that requires relatively extensive training. EKG technicians are often cross-
trained on the job in exercise testing, another noninvasive cardiology pro-
cedure.

The associations that represent cardiovascular technicians who do EKGs
and exercise tests have established a separate board to test technicians who
want to be credentialed; most technicians are not credentialed. Institutions
in which these technicians work encourage credentialing but do not require
it. Cardiovascular technicians are employed in a variety of settings including
physicians’ ofﬁces, outpatient clinics, and exercise clinics. They work under
the supervision of nursing staff or physicians.

Technicians who specialize in echocardiograms are often trained on the
job. Only 6 of the 30 schools offering ultrasound training include training
in echocardiography, and none of the schools is accredited under CAHEA’s
new program of essentials for cardiovascular technology. Training in these
programs must generally be supplemented by on-the-job training, but not
all health care facilities have the capability to train the echocardiography
technicians they need. The demand for these technicians is high, and their
salaries are rising. They are often drawn from other disciplines, including
nursing, physical therapy, and respiratory therapy; few trainees are without
a medical background.

WHAT DOES “ALLIED HEALTH" MEAN? 41

The Society of Diagnostic Medical Sonographers represents echocar-
diographers and other sonographers. Two boards currently provide testing
for certiﬁcation in the ﬁeld. Generally, individuals need to have several
years of experience before they can qualify to take the exam. The majority
of echocardiographers are not board certiﬁed, but interest in certiﬁcation
is growing—and growing faster than in any of the other cardiovascular
technology areas. The American College of Cardiologists is encouraging
certiﬁcation through only one body, which will probably provide increased
impetus for such credentialing.

Although echocardiographers have some degree of autonomy, they work
closely with physicians. Echocardiography overlaps with radiologic tech-
nology, which includes ultrasound technology or sonography. A movement
to draft state legislation requiring that ultrasound operators be radiologic
technicians is being fought by non—radiologic technicians who work with
ultrasound technology.

Invasive cardiovascular technologists, as their title suggests, assist phy—
sicians in invasive heart procedures. With the development of bypass sur-
gery the number of catheter labs has risen, and the demand for technologists
has grown. Developments in balloon angioplasty and laser technology may
have the same effect. Practitioners generally are drawn from other clinical
areas, including x-ray technology and nursing, and typically are trained on
the job.

Noninvasive peripheral vascular technologists assist in diagnostic studies
of the peripheral circulatory system. Ultrasound techniques are used in
these studies, and, as in the case of echocardiography, substantial training
is required for technicians; in addition, like echocardiographers, nonin-
vasive peripheral vascular technologists who conduct ultrasound tests also
face competition from radiologic technologists. Equipment manufacturers
have been the primary source of training; they have established educational
programs in their own facilities as well as providing onsite, in-service train-
ing. In its early days, most of the ﬁeld’s trainees were nurses, but it now
draws persons from other disciplines.

CONCLUSION

Allied health practitioners vary greatly in terms of the work they do, the
amount of education they require, the types of institutions they attend to
obtain that education, and the regulatory control that attends their activities.
Yet, the evolution of their professions has followed courses that were com-
mon to several if not to all of the ﬁelds. The ﬁelds developed to meet
identiﬁed health care needs, often taking over tasks that physicians no
longer wanted to undertake. Initially, on-the—job training was the norm,
but soon the practitioners of a ﬁeld formed an organization, deﬁned their

42 ALLIED HEALTH SERVICES

roles, and identiﬁed minimum qualiﬁcations that all practitioners must
possess.

The certiﬁcation of practitioners and the accreditation of educational
programs followed. Many allied health ﬁelds today use CAHEA to accredit
their programs. Others have preferred to keep accreditation within the
purview of the ﬁeld, a decision many groups see as one of the key attributes
of a profession. In many of the ﬁelds, educational requirements have
increased almost inevitably, and licensure often has followed, a develop-
ment that serves several purposes including the protection of a practition—
er’s educational investment. In many of the allied health ﬁelds, tensions
developed between practitioners and the medical or dental speciality from
which the ﬁeld developed. New professions have sought to control their
own destinies while the originating professions have sometimes been re-
luctant to relinquish control, in part because they fear competition from
the very groups they initially encouraged in order to relieve themselves of
unwanted tasks.

Some allied health ﬁelds (e.g., physical therapy) made the transition from
hospital training to baccalaureate education in universities and colleges in
the ﬁrst half of the century. With the community college movement in the
1960s, assistant-level programs developed to meet the growing demand for
services and the need to make practitioners more productive. For other
ﬁelds the transition to education and training in academia was made much
more slowly. For example, radiography and respiratory therapy are in the
midst of evolving toward requiring the baccalaureate degree; consequently,
we now see some l—year programs giving way, primarily to 2—year and
baccalaureate programs. Those individuals with advanced degrees tend to
gravitate toward administrative roles.

The spectrum of allied health today includes ﬁelds at different stages of
evolution. This report offers a snapshot of them at one point in time.

REFERENCES

American Dietetic Association. 1972. The Profession of Dietetics: Report of the Study
Commission on Dietetics. Chicago: American Dietetic Association.

American Dietetic Association. 1985. A New Look at the Profession of Dietetics: Report
of the 1984 Study Commission on Dietetics. Chicago: American Dietetic Association.

American Dietetic Association. 1987. Unpublished data. American Dietetic A sociation,
Chicago

AOTA (American Occupational Therapy Association) 1986.1986 Member Da a Survey.
Rockville, Md. American Occupational Therapy Association.

APTA (American Physical Therapy Association). 1987. 1987 Active Membersliip Proﬁle
Survey. Alexandria, Va.: American Physical Therapy Association.

American Speech—Language—Hearing Association. 1988. Demographic Proﬁle of ihe ASHA
Membership. Rockville, Md.: American Speech—Language—Hearing Afisociation.
March 9. ‘

WHAT DOES “ALLIED HEALTH" MEAN? 43

Bryk, J. A. 1987. Report on the 1986 Census of the American Dietetic Association. Journal
of the American Dietetic Association 87(8):]080—1085.

Bureau of Health Manpower. 1967. Education for the Allied Health Professions and
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ﬁce.

Bureau of Health Professions. 1984. An In-Depth Examination of the 1980 Decennial
Census Employment Data for Health Occupations, Comprehensive Report. Rockville,
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Bureau of Health Professions. 1988. Report to the President and Congress on the Status
of Health Personnel in the United States. Washington, DC: U.S. Department of
Health and Human Services.

Bureau of Labor Statistics. 1987. Employment by Occupation and Industry, 1986 and
Projected 2000 Alternatives. Washington, DC: Bureau of Labor Statistics.

Committee on Allied Health Education and Accreditation (CAHEA). 1987. Allied Health
Education Directory, 1987. Chicago: American Medical Association.

McTernan, E. J. 1987. Allied health professions in the United States: A summary of the
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Role of Allied Health Personnel.

Paden, E. P. 1970. A History of the American Speech and Hearing Association. Wash-
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Shewan, C. M. 1987. An update on supply estimates for speech—language—hearing per-
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2

Approaches to Measuring
Demand and Supply

 

ONGRESS DIRECTED that this study “identify projected needs, availa-

bility, and requirements of various types of health care delivery systems
for each type of allied health personnel.” Before it could respond to this
charge, however, the committee had to resolve several issues of scope and
approach.

1. Current versus future “needs, availability, and requiremenls” The com-
mittee believes that, given its limited funds and time, it can make a greater
contribution by providing its best assessment of future needs and require-
ments for allied health personnel and its best assessment of the kinds of
adjustments that will be needed to meet those needs and requirements.
Although it recognizes that there is intense interest in the current situation,
the committee believes that most of the study’s resources would have been
exhausted in performing a systematic assessment of that situation. The
future outlook, on the other hand, is crucial to strategic planning and
policy; therefore, the committee chose to devote most of its efforts to
developing a picture of the future. To the extent that it became aware of
perceptions of current imbalances in demand and supply of allied health
personnel as the study progressed, those perceptions are noted in the
report.

2. “Each type of allied health personnel” As the charge implied and the
committee clearly recognized, it is neither feasible nor useful to consider
the needs and availability of allied health personnel collectively. The allied
health rubric comprises occupations with varying labor market character-
istics (e.g., paths of entry, levels and types of responsibilities, wages and

44

MEASURING DEMAND AND SUPPLY 45

salaries, labor force entries and exits, and work sites). As a consequence
the demand and supply situation must be considered separately for each
occupational ﬁeld. The approach used in this study has been to examine
10 allied health ﬁelds in some depth to illustrate the diversity among them.
To the extent possible, these ﬁelds are used as the basis for several general
conclusions about the future employment outlook.

3. “Needs, availability, and requirements” Two different approaches are
implied by the charge. “Needs,” as used in the context of health personnel
planning, refers to a normative idea of the number and type of personnel
required to provide therapeutic and preventive services to a deﬁned pop-
ulation. Need is usually deﬁned independently of economic constraints.
Demand (or effective demand), on the other hand, refers to the number
and type of personnel required to ﬁll the available jobs and provide services
for which consumers are willing and able to pay.

The committee elected to assess future needs and requirements in terms
of the effective demand for allied health personnel. This decision was based
on the committee’s judgment that this approach is of most use for realistic
planning. However, in the case of long-term care (see Chapter 8), the
committee chose to take a patient-centered approach in examining the
future need for allied health personnel.

4. Planning horizon The committee selected the year 2000 for its pro-
jections of future demand and supply. Because most of the available base
data are for 1986, this decision means, in effect, looking ahead 15 years.
The committee recognizes the great uncertainty that goes with so long a
horizon. Yet many decisions require some assessment of the future, how—
ever rough, and the types of decisions that affect the labor market for
allied health practitioners (e.g., starting or modifying educational pro-
grams) necessitate long lead times. On balance, then, the committee’s de-
cision was to take the long view.

DATA FOR ASSESSING DEMAND AND SUPPLY

The committee was limited to the use of existing data as the basis for its
assessment of demand and supply in allied health ﬁelds because it was not
possible to design, ﬁeld, and analyze a survey within the available study
time, particularly considering the requirement for the Ofﬁce of Manage-
ment and Budget’s approval of such a survey. The paucity of existing data
on allied health ﬁelds severely constrained the committee’s ability to carry
out its charge. Thanks in large part to signiﬁcant federal investments in
developing data bases in medicine, dentistry, and nursing, previous Insti—
tute of Medicine (IOM) studies of those fields have been able to draw on
large amounts of data and on requirements and supply projections made
by the Bureau of Health Professions of the Department of Health and

46 ALLIED HEALTH SERVICES

Human Services based on those data. In the allied health fields, however,
data are limited. ‘

Nonetheless, some data do exist. BLS collects information on employ-
ment, earnings, and labor force behavior of a number of allied health
occupations in its ongoing analysis of the U.S. work force. The decennial
censuses and the Current Population Survey offer detailed information by
occupation. In addition, allied health associations conduct surveys of their
members that provide invaluable data on persons meeting their member-
ship criteria. Associations of hospitals, nursing homes, and home health
care agencies also collect data on employment in their constituent institu-
tions.

The committee has examined these and other data sources to inform its
assessment of personnel demand and supply. In the sections that follow,
we point out problems and weaknesses in the data and offer some sug-
gestions for improvement that, if heeded, will ease the way for future
studies.

ASSESSING CURRENT DEMAND AND SUPPLY

How do we know if there is a current shortage of allied health personnel?
This is not a straightforward question. First of all, the term shortage has a
variety of meanings. Sometimes it is deﬁned normatively: a shortage exists
if there are fewer respiratory therapists than are needed, according to some
deﬁnition of need. Economists define a shortage as a situation in which
fewer people are employed than employers would like to employ at the
current wage. Although they may be cognizant of other factors that inﬂu-
ence employers’ decisions to employ workers and prospective employees’
decisions to seek work, economists traditionally focus on levels of salaries
and wages, and sometimes on fringe beneﬁts, as the principal variables that
equilibrate employer demand and the labor supply.* According to eco-
nomic theory, if the labor market were functioning properly, a shortage
could exist only temporarily because employers would pay more to attract
more workers until all jobs were filled. Thus, economists view any labor
shortage as reﬂecting either a lag in the adjustment of the labor supply to
demand or an imperfection in the functioning of the labor market. For
example, if the demand for labor grows at a rapid rate over a period of
time, a temporary labor shortage may occur. Barriers to adjustment can
also result in labor demand and supply not coming into balance. These
factors will be described later.

*This explanation is somewhat oversimpliﬁed, however, because other aspects such as the
risk involved in work and working conditions are also considered in economic analyses of
labor d:mand and supply.

MEASURING DEMAND AND SUPPLY 47

A shortage can occur over the short term or the long term, although
long—term shortages are unusual unless there is some market imperfection
such as a price ceiling that prohibits market adjustments. In the short term,
workers must be recruited from the existing pool, and employers must use
existing technology. Over the long term, however, new workers can be
trained and new technologies employed to change the nature of the work.

Indicators of 21 Labor Shortage

A number of signals can indicate that labor shortages exist. Such signals
include large numbers of job vacancies, rising compensation levels, and low
unemployment levels.

Vacancies

The most commonly cited indicator of a labor shortage is job vacancies.
A large number of vacant positions or a high ratio of vacancies to total
employment is taken as evidence of a shortage. “Large” and “high,” of
course, are relative to some expected level of vacancies. This expectation
may be based on historical vacancy levels for the occupation of interest or
on a comparison with current vacancy levels in other occupations.

There are some vacancies in an occupation at all times because of job
turnover. Because job mobility is important to a well-functioning labor
market, such vacancies can be viewed as a sign of the market’s health rather
than its pathology. As Hall (1978) has pointed out,

The role of vacancies can only be understood against the background of the ceaseless
motion within the labor market. . . . Every month, several million workers change
jobs, and hundreds of thousands of others move in and out of the labor force.
Much of this turnover is attributable to ﬂuctuations in the labor requirements of
individual employers and the rest to the changing circumstances of individual
workers.

Vacancy rates are not reliable indicators of job opportunities for several
reasons. For one thing, the highest rates occur in occupations with the
highest turnover; construction work is an example often cited. Among the
health occupations, turnover is much higher for nurses’ aides than for
highly trained personnel (e.g., medical technologists or physical therapists).

In addition, reported vacancies should be viewed with caution because
they do not always represent a shortage. If, through one mechanism or
another, wages are kept below the level that would bring demand and
supply into equilibrium, employer demand will always exceed the number
of allied health personnel who want to work at the going wage. Such excess
demand cannot really be characterized as a shortage but rather as an
imperfection in the operation of the market.

48 ALLIED HEALTH SERVICES

Sloan (1975), Yett (1975), and others have pointed out in the context of
nursing that if the labor market is not competitive and therefore one or
several employers have some control over wage levels, the market can be
in equilibrium even though there are vacant jobs. In this case, an employer
would report vacancies but would not raise wages to ﬁll them. Another
possible explanation for market equilibrium in the midst of vacancies is
the systematic undervaluation of work in occupations in which female
workers predominate. Institutional barriers—longstanding custom, the
misperception of market conditions by employers, and inﬂexible recruit-
ment practices—rather than an insufﬁcient number of qualiﬁed persons
available to work may account for vacancies.

Compensation Levels

Another signal that is often interpreted as indicating a shortage is rising
compensation levels. Wages are the element that is most easily observed,
but compensation in this instance means the entire package offered by
employers: wages or salaries, beneﬁts, hours, and conditions of work. If
employers are unable to attract workers with their current package, pre-
sumably, they will improve it. Increases in compensation levels, however,
are not in themselves evidence of a shortage. Rather, they may indicate
normal and often temporary market adjustments in an environment of
rising demand.

Relative changes in compensation levels are better indicators of labor
market conditions than are absolute changes. If the earnings of physical
therapists are rising much faster than earnings in, for example, medical
technology or teaching (ﬁelds that require similar educational investments)
and if employers are unable to ﬁll vacant physical therapist positions, we
might conclude that there is a shortage, or at least that, at present, demand
is outstripping supply. If market signals are sufﬁciently strong—that is,
compensation rises, unemployment drops, and so forth—the shortage pre—
sumably would be alleviated over time by new entrants to the physical
therapy ﬁeld. The interim may bring painful dislocations, however. Services
may have to be curtailed, or substitute workers may have to be employed,
with an unacceptable decrement in quality. In some industries, of course,
such dislocations are viewed as normal.

Unemployment Levels

Some frictional unemployment (a level of unemployment resulting from
the time involved in changing jobs) is characteristic of a dynamic labor
market in which people Change jobs, often with an interval in between.
Unemployment levels will tend to be relatively higher in occupations with

MEASURING DEMAND AND SUPPLY 49

high turnover. Very low unemployment levels (virtually everyone seeking
employment is ﬁnding it) are another signal that may indicate a labor
shortage. Low unemployment levels are especially indicative of shortages
if vacancy levels remain high.

The employment experience of new graduates is one indicator of con-
ditions in the labor market. If, for instance, most physical therapy graduates
find work in the ﬁeld within a year after graduation, the labor market may
be tight. As with the other signals mentioned above, however, caution must
be exercised in interpreting such signals. New graduates can be hired at
lower wages than experienced therapists, and some employers may prefer
to substitute less experienced workers for more experienced ones to keep
costs down. In addition, new graduates tend to be more mobile; therefore,
their experience may be more favorable than that of other, less mobile
workers.

Any one of these signals alone does not indicate a shortage. On the other
hand, when a number of them occur together, especially if they persist
over time, it becomes ever more likely that there is a real problem. If
employers are constrained from making such adjustments as substituting
less highly trained employees for more highly trained ones (for example,
substituting corrective therapists for physical therapists) or importing work-
ers from abroad, or if the necessary adjustments are unacceptable to society,
it would be fair to call the problem a labor shortage.

Data for Assessing Current Vacancies

National data on job vacancies are not available. For both technical and
budgetary reasons, BLS does not collect vacancy data. The American Hos-
pital Association collects data on allied health employment but not on
vacancies. Qualitative assessments are often made in surveys of local em-
ployers by, for example, education administrators. Surveys by professional
associations may include questions about their members’ perceptions of the
labor market in their communities. Anecdotal data are reported in health
care journals and newsletters from time to time. In addition, regional or
state development bodies such as the state-sponsored Massachusetts Tech-
nology Development Corporation sometimes attempt to make assessments.

Data on Salaries and Wages

The BLS Industry Wage Survey program collects and publishes average
straight-time hourly wages for selected occupations in hospitals and nursing
homes in 23 standard metropolitan statistical areas (SMSAs). Hospital sur-
veys were conducted in 1978, 1981, and 1985; the allied health occupations
that were covered included diagnostic medical sonographers, electroen—
cephalographic technicians, electrocardiographic technicians, medical lab-

50 ALLIED HEALTH SERVICES

oratory technicians, medical technologists, nuclear medicine technologists,
radiation therapy technologists, radiographers, surgical technologists, die-
titians, medical record administrators and technicians, and all of the therapy
occupations. The survey excluded such elements of compensation as pre-
mium pay for overtime and work on night shifts or holidays and such in-
kind compensation such as room and board. Fringe beneﬁts were also
excluded. These data are quite useful for examining trends in basic wages
in urban hospitals and nursing homes and for comparing wage levels
among SMSAs.

Occupational earnings are available from the Census Bureau’s Current
Population Survey. Data on the earnings of allied health association mem-
bers are collected through member surveys. In addition, the University of
Texas Medical Branch at Galveston annually surveys 33 hospitals, 16 med-
ical schools, and 28 medical centers.

Unemployment statistics are collected monthly by BLS. Although ex-
tremely useful in the aggregate, these data have some weaknesses when
used to assess market conditions in speciﬁc occupations. Unemployed per-
sons are classiﬁed by the occupation in which they were last employed.
Thus, a person seeking work as an audiologist whose last job was as a
teacher would be categorized as an unemployed teacher. Recent graduates
seeking their ﬁrst job are excluded from the unemployment ﬁgures by
occupation. As with other market indicators, BLS occupational unemploy-
ment data must be used carefully and only after being critically examined.

Surveys by allied health professional associations generally elicit infor-
mation on whether their members are employed and where. Less fre-
quently do they provide information (e.g., whether the respondent is looking
for work) that would complement data from the Current Population Sur-
vey. CAHEA‘ has conducted surveys of education program directors about
offers to their graduates as a means of assessing the job market; some state
education departments conduct similar surveys. In addition, individual
educators sometimes survey employers in their community regarding em-
ployment opportunities.

How to Improve Data on Current Allied Health
Personnel Demand and Supply

The balance between the current demand for and supply of allied health
personnel is of concern to a wide range of organizations, to educators
seeking jobs for their students, to facility administrators who are unsure
about the availability of needed personnel, and to allied health practitioners
and the associations that represent them, all of whom are concerned about
jobs, compensation, and career prospects. In functional terms an assessment
of current personnel demand and supply is the essential baseline data point
from which projections start. Current information about the labor market

MEASURING DEMAND AND SUPPLY 51

also enables those in positions to do so to act early to prevent the occurrence
of serious imbalances and the need for major corrective action later.

In the previous sections, we have noted the types of data that are needed
to estimate current demand and supply. Some of these types of data are
available but usually only for certain allied health ﬁelds in some localities.
Health care institutions are already responding to heavy demands for op-
erating data and are reluctant to add to their burden in the absence of a
belief that such data will serve their interests. Additional data collection
activities should be undertaken only after a careful consideration of the
benefits of such efforts and of ways to minimize the burden of undertaking
them. The data to assess current labor market conditions are more readily
available for other health care professions—such as physicians and nurses—
than for allied health ﬁelds. The committee believes that the lack of data
about allied health fields, compared with the data available on other types
of providers, reﬂects an underestimation of the role of allied health prac-
titioners in the health care system. Both the large contribution to care made
by such practitioners and the high total costs associated with the aggregate
use of allied health professionals strongly suggest that data collection strat-
egies that allow the assessment of current personnel demand and supply
should be seriously explored.

For example, associations of employers could try to develop simple,
inexpensive surveys to learn about problems in recruiting. Survey questions
might include the following: What kinds of employees are you finding the
most difﬁcult to recruit? Are you using any exceptional recruitment mea-
sures? What actions are you taking to cope with vacancies? These surveys
might be conducted in a small sample of “sentinel” institutions as frequently
as tw1ce a year.

Professional associations should use standard labor statistics terminology
to increase the usefulness of their surveys to BLS and vice versa. It is
especially important to count people who are not working but who are
actively seeking work; these are the people the US. Department of Labor
categorizes as unemployed. Professional associations should also explore
longitudinal studies of a sample of their members; studies of this type could
provide better data on members’ work histories, labor force participation,
earnings, and other characteristics than can be gathered from the cross-
sectional surveys that are usually conducted. In addition to technical im-
provements, associations should look for ways to make their research more
relevant to current policy issues. Associations would be well served to
strengthen the links between their research and policy functions.

The committee also recommends that the US. Department of Health
and Human Services’ Health Resources and Services Administration (HRSA)
reconstitute the Forum on Allied Health Data as a technical assistance
endeavor. HRSA should also hold workshops with experts in survey design,

52 ALLIED HEALTH SERVICES

statistics, and labor economics to help the allied health associations improve
their data collection programs. Other possibilities for improving the infor-
mation on current labor market conditions for allied health personnel
include the following:

0 When renewing licenses, state licensing bodies could ask whether ap-
plicants are currently employed in their ﬁeld, employed in another occu-
pation, looking for work, or not looking for work.

0 State and regional health planning agencies could make larger in-
vestments in education and employment data and planning. They could
also operate as an important link between educational institutions and
employers.

0 Educational institutions could pool information on the job—ﬁnding
experiences of recent graduates and alumni. Local experience could be
aggregated to develop state and national pictures.

ASSESSING FUTURE DEMAND AND SUPPLY

Forecasts of the future are often inaccurate, either because they do not
take into account all of the relevant factors or because the factors change
in ways that were not or could not have been predicted. Yet decision making
is based on assumptions about the future, however crudely they are formed.
The committee’s task has been to use the limited data available to formulate
a “best guess” and to let that projection inform its recommendations. Thus,
the committee’s recommendations are based on the interpretation of gen—
eral trends in the work force and in the economy and of speciﬁc projections
for selected allied health ﬁelds.

Several approaches are possible to assess future needs and requirements
for allied health personnel. Some of the approaches that have been used
for other types of health manpower ﬁelds are described below to illustrate
the available assessment options, the ways they can be used, and the types
of data that are needed for their use.

Needs-based projections usually deﬁne the number of personnel re-
quired to provide a given set of services to a deﬁned population. The needs
approach, which was pioneered by the Committee on the Costs of Medical
Care in the 19305, involves two types of judgment: (1) the quantity and
type of health care services judged to be appropriate, and (2) the appro-
priate division of responsibility for those services among the various types
of health care personnel. The projections that ﬁnally result depend on who
makes these judgments and on their views of what constitutes good health
care. Needs-based models represent an unconstrained social idea]: they are
norms against which to compare actual performance. They can be used to
establish health care program objectives and to assess the probable avail-
ability of personnel to meet those objectives.

MEASURING DEMAND AND SUPPLY 53

The Graduate Medical Education National Advisory Committee, which
was established by the secretary of health and human services in the late
1970s, used a needs-based approach to project physician requirements for
1990. The committee began with estimates of the incidence of particular
illnesses or medical conditions in the population and then made judgments
about which conditions required medical care, how many visits would be
required, and how many of these visits might be “delegated” to persons
other than physicians. The total estimated visits were transformed into
physician requirements based on assumptions about productivity (Iacoby,
1981)

A model of requirements for nurses developed by the Western Interstate
Commission on Higher Education also had its foundations in judgments
of need. Panels of nurses provided professional judgments about desirable
changes in health care delivery and about the mix of registered nurses
(RNs) and licensed practical nurses (LPNs) needed to provide the desired
services (Bauder, 1983).

Another approach to projecting health care human resources require-
ments is to extrapolate from current levels. Instead of assigning ideal health
care services utilization levels (and their corresponding health care per-
sonnel requirements) to projected population segments, current utilization
levels are projected into the future. Most simply, current health care per-
sonnel-to-population ratios are applied to population projections. The Bu-
reau of Health Professions of the Department of Health and Human Services
uses this method to project physician requirements by starting with current
utilization levels and then adjusting for projected changes in population,
trends in health insurance beneﬁts, and other factors that affect utilization
such as the cost of health care services. Productivity assumptions are used
to translate projected utilization into the number of physicians required.
The Division of Nursing also employs a model that projects population,
per-capita use of health care services, and the associated required numbers
of RNs and LPNs.

The simplest extrapolation models are strictly mechanical; the health
care personnel—to—population model is an example. More sophisticated models
incorporate “behavioral” components, such as the price elasticity of demand
for health care services, and then make independent projections of prices.
They may also incorporate changes in production technology—for ex-
ample, capital—labor substitution or the division of tasks among health care
personnel.

As extrapolation models become more sophisticated, they begin to re—
semble models of economic demand. A demand model is based on the
relationship of such independent variables as health status, income, and
prices to the demand for health care services. In the case of labor demand,
the model is based on such variables as wages, the price of capital, and
product prices. Although not strictly a demand model, the BLS projections

54 ALLIED HEALTH SERVICES

of employment are made in the context of projected labor force and eco-
nomlc act1v1ty.

The committee chose to rely heavily on the BLS employment projections
for its assessment of future demand. The principal reasons for this reliance
were the following:

0 The BLS projections are grounded in projections of the entire econ—
omy, which include projections of the work force and levels of economic
activity. Health care expenditures and health care industries employment
are estimated in the context of growth in other types of expenditures and
employment in all other institutions.

0 BLS’s projections use a consistent methodology across occupations.
Not only can the allied health occupations be compared with each other,
but they can be viewed in the context of all other occupations for which
projections have been made in the same way.

0 The BLS projections are widely known and used; they are reviewed
regularly and revised biennially. '

The committee did not, however, use these projections uncritically. It
took several factors into account in using the BLS data:

0 Occupational employment projections are subject to considerable er-
ror, more so than the projections of total employment by industry.

0 BLS staff use their knowledge and judgment to project the number
of jobs for each occupation in an industry. For the health care industry,
many judgments have to be made about how changes in health care f1-
nancing and delivery will affect different occupations. Because these judg-
ments by BLS staff are not published, it is difﬁcult to subject the results
to a critical assessment.

0 The occupational deﬁnitions used by BLS are not identical to those
of professional associations or educators. Although great improvements
have been made in the system of occupational classiﬁcation, BLS deﬁnitions
still rely more heavily on functions and less heavily on credentials. In
addition, the data are not adequate in some cases to distinguish among
different levels within occupations. For instance, BLS combines data for
laboratory technologists and technicians. In some instances (e.g., for per-
fusionists, dialysis technicians, and cardiovascular technologists), no em-
ployment projections are made. (See Appendix E for further 'discussion
and evaluation of BLS data.)

HOW BLS MAKES EMPLOYMENT PROJECTIONS

Because the committee relied heavily on BLS for its assessment of future
demand, it is important to understand how these projections are made.

MEASURING DEMAND AND SUPPLY 55

BLS projections are made from a base year to a target year. The base for
the bureau’s most recent projections was 1986; the target year was 2000.
Harold Goldstein, in a background paper (1987) prepared for the com-
mittee, characterized the BLS approach as follows:

The basic approach followed is to estimate the employment in each occupation that
will be generated by economic demand. This goes back to the demand for the
goods or services the occupation provides, and this in turn is affected by the total
spendable income available to consumers and government and to the changing
patterns of what they spend it on. These are inﬂuenced by a wide variety of social
and economic factors, including changing tastes and styles, scientific discoveries
and technological change affecting both what is produced and how it is produced,
the growth and changing composition of the population, taxation and government
expenditures policies (“guns or butter”) and what other countries are buying from
and selling to us.

There are several steps in the projection sequence, the ﬁrst of which is
the projection of the labor force. The foundation for this projection is the
Census Bureau’s population projections by age, sex, and race, which are
based on assumptions about birth rates, death rates, and migration in and
out of the United States. Labor force participation for each age, sex, and
race group is projected by extrapolating from past participation rates. The
projected labor force participation rates are applied to the corresponding
population projections to arrive at the projected labor force in the target
year.

Next, BLS uses a macroeconomic model to develop projections of the
gross national product (GNP) and major categories of demand and income.
Some of the assumptions that affect the macroeconomic model, such as
population projections, are fairly certain; other assumptions, such as net
imports, energy prices, and the exchange value of the dollar, are quite
uncertain, depending as they do on international political and economic
developments. Because assumptions about certain key variables have major
impacts on the projections, BLS produces three sets of macroeconomic
projections based on differing sets of assumptions. These assumptions in-
volve the levels of expenditures in major components of federal spending,
the major components of state and local government spending, the size
and composition of the population, and the key variables underlying for-
eign trade. Low, medium, and high projections of GNP are then produced
from differing assumptions for each of these variables (Table 2—1).

The effect of these variations in assumptions can be seen in the figures
for GNP and employment. The low, moderate, and high GNP projections
that result from these and other assumptions are (in billions of dollars)
$4,617, $5,161, and $5,552, respectively. The corresponding projections
of total employment (in thousands) are 126,432, 133,030, and 137,533
(Monthly Labor Review, 1987).

56 ALLIED HEALTH SERVICES

TABLE 2-1 Assumptions Used in Making Spending and Labor Force
Projections for the Year 2000

 

 

Variable Low Moderate High
Federal defense spending (35 billions) 222.5 251.0 263.0
Federal nondefense spending (35 billions) 97.3 103.4 108.2
State and local spending on education ($ billions) 195.3 223.1 232.5
Size of the civilian labor force (millions) 134.5 138.8 141.1

 

BLS next estimates the principal GNP components: personal consump-
tion of durable and nondurable goods and services, capital investment,
foreign trade (imports and exports), and government expenditures. These
’ estimates of ﬁnal demand are translated into estimated levels of production
for each industry in the economy using an input—output table based on
historical relationships that is compiled by the Department of Commerce.
The input—output table shows what each industry in the economy pur-
chases from every other industry. For example, the automobile industry
purchases raw materials (iron ore), intermediate products (tires and glass),
and services (electrical power and transportation) from other industries to
produce its ﬁnal product, automobiles (Goldstein, 1987). This step in the
projection process results in estimates of the level of production for every
industry in the target year.

The next-to-last step is the estimation of total employment for each
industry from a regression equation that estimates worker-hours as a func—
tion of industry output, the unemployment rate (a measure of capacity
utilization), the relative price of labor, and the ratio of output to capital.
The estimated worker-hours are translated into the number of workers by
dividing worker-hours by the estimated annual hours per worker.

Finally, BLS develops estimates of occupational employment by industry,
using base year data on the distribution of industry employment by 0c-
cupation. Sources of data for these estimates include the Occupational
Employment Survey conducted periodically by state employment security
agencies under a BLS—state cooperative program (see Appendix E for a
discussion of CBS and other data sources), the decennial census, and the
Current Population Survey. In projecting occupational employment in each
industry, adjustments are made in the occupational composition of the
industry.

In the BLS estimates, the health services industry is broken down into
components that reﬂect the different employment settings (e.g., hospitals,
physicians’ ofﬁces, nursing homes). The next step of the process takes into
account factors that are not explicitly included in the mathematical model.
BLS analysts with responsibilities for speciﬁc occupations consult experts
(e.g., the staff of the professional associations), use the relevant literature,

MEASURING DEMAND AND SUPPLY 57

and make site visits to assess whether stafﬁng patterns are likely to change
and if so, how they will change. Because the aggregate employment for
each industry provides the parameters of employment, BLS analysts confer
with each other to determine how each occupation in each industry will
fare relative to one another. For example, the analysts who follow health
occupations will meet to discuss hospital stafﬁng patterns, the changes that
are expected, and why those changes will occur. Factors that are taken into
account include new technologies that are likely to change stafﬁng intensity,
changes in insurance coverage, and regulatory policies that may inﬂuence
the demand for a service or individual occupation.

Table 2-2 shows the BLS low, moderate, and high projections of em-
ployment in the allied health ﬁelds for the year 2000. The differences
among the three projections are attributable to different assumptions about
economic growth and aggregate employment. The same assumptions about
and adjustments to the occupational distribution of employment are used
in all three groups of projections.

TABLE 2-2 Bureau of Labor Statistics Wage and Salary Employment
(in thousands) in the Allied Health Fields, Actual for 1986 and
Projections for the Year 2000

 

Projected Employment for
the Year 2000

 

1986 __—__._

Occupation Employment Low“ Moderateb High‘
Clinical laboratory technologists and

technicians 238 285 296 307
Dental hygienists 87 134 141 145
Dietitians 40 52 54 55
Emergency medical technicians 65 73 75 77
Medical record technicians 40 67 70 72
Nuclear medical technologists 10 12 12 12
Occupational therapists 26 43 45 46
Physical therapists 56 109 l 15 118
Radiologic technologists and

technicians 114 183 190 196
Respiratory therapists 56 74 76 78
Speech—language pathologists/

audiologists 42 58 61 63

 

“The low projection reflects annual growth rates of 1.6 percent in GNP, 1 percent in
the civilian labor force, and 0.9 percent in employment.

bThe moderate projection represents annual growth rates of 2.4 percent in GNP, 1.2
percent in the civilian labor force, and 1.2 percent in employment.

”The high projection represents annual growth rates of 3 percent in GNP, 1.3 percent
in the civilian labor force, and 1.5 percent in employment.

SOURCE: Silvestri and Lukasiewicz, 1987.

58 ALLIED HEALTH SERVICES

FUTURE SUPPLY

In a dynamic labor market the supply of workers in an occupation is
constantly changing. New graduates emerge from education programs.
People enter the labor market who have worked in other occupations or
who have studied related subjects. Individuals leave the work force and
later reenter; some leave permanently.

Projecting the future supply of workers in an occupation requires, first,
an estimation of how many people are in the field in a base year and then
an estimation of the various inﬂows and outﬂows that will occur between
the base year and the target year. Which inﬂows and outﬂows are important
depends on the purpose of the projection.

For example, in the nursing ﬁeld, there has been concern voiced about
the many trained nurses who are outside the nursing work force, either
working in other ﬁelds or not working at all. Although data on licensed
nurses provide a picture of those nurses who keep their licenses active,
some have argued that there may be many nurses who have dropped their
licenses but who, in some sense, constitute a potential supply. If market
conditions warrant, the argument goes, these nurses could be attracted
back to work, even if some retraining were necessary. This pool of trained
workers can be estimated and projected using data on the number of
graduates and applying standard mortality rates to each age group. The
supply estimated by this life table approach represents an estimate of all
living nursing graduates (Institute of Medicine, 1983). For this purpose,
the only inﬂow is new graduates, and the only outﬂow is death.

However, if the question is whether there will be enough nurses to fill
the jobs that we expect to be available in the future, more information is
needed about the likelihood that those who are not in the work force will
reenter it. We also need to know about the likelihood that nurses who are
in the work force will leave. Variations in the rates of reentry and loss from
the labor force and the average time practitioners spend in the labor force
produce large differences in the supply projected for the future. For most
purposes, it is the “effective” supply of health personnel, trained and want—
ing to work, that is of greater interest.

The committee, where feasible, has projected the future supply of work-
ers in allied health fields in the year 2000, assuming inﬂows to and outﬂows
from the labor market remain as they were in 1986 and the number of
allied health program graduates remains at the current level. These as-
sumptions are unrealistic, but they are used to indicate the magnitude of
change that must take place to meet future demand. The committee used
a simple arithmetic equation to arrive at its projections. The work force at
the beginning of one year was said to equal the work force at the beginning
of the year before, minus those persons leaving the work force for reasons

MEASURING DEMAND AND SUPPLY 59

other than unemployment, plus graduates of allied health programs and
other additions. These additions include people resuming work and people
transferring from other occupations.

The base year for our observations was 1986. To achieve comparability
among ﬁelds, the BLS estimate of total employment for each occupation
was used. An estimated number of unemployed practitioners was added
in each case.

For some allied health ﬁelds the number of graduates in 1986 was as-
sumed to remain constant through the year 2000. When it was reasonable
to do so, the 1986 share of bachelor’s degrees granted in a ﬁeld, relative
to all bachelor’s degrees granted, was applied to the Center for Education
Statistics’ projection of bachelor’s degrees to be granted each year through
2000.

Labor force accession and separation rates that BLS derives from Current
Population Survey data were used to determine additions to and losses
from the work force. Because the sample size of most allied health ﬁelds
in the survey is small and estimates are subject to great sampling variability,
we used rates of labor force accession and separation for larger groups.
For example, the rates for therapists overall were applied to physical, oc-
cupational, and respiratory therapists separately. In approximating addi-
tions to the work force, the accession rate for 1983—1984 was applied to
the 1984 work force to generate an estimate of the number of persons
who joined the work force in 1984. That number was held constant each
year.

Chapter 4 brings together the committee’s information about the de—
mand for and supply of allied health practitioners. The BLS employment
projections for each ﬁeld to the year 2000 are evaluated in light of expec-
tations about the forces that drive demand. The results of the process to
estimate the supply of workers that has been described in this chapter are
compared to the expected demand. To this, the committee has added its
knowledge of how the ﬁelds are faring in current labor markets and the
trends in the ﬁelds in numbers of graduates and programs to make an
assessment of the future balance between demand and supply.

DATA FOR PROJECTING THE FUTURE SUPPLY OF
ALLIED HEALTH WORKERS

Current (Base Year) Supply

The BLS Industry—Occupational Employment matrix estimates the number
of employed persons in each of 480 occupations. It is not an unduplicated
count; wage and salary workers holding two jobs would be counted twice.
The most recent data, used as the base for employment projections to the

60 ALLIED HEALTH SERVICES

year 2000, were for 1986. The next year for which these data will be
available is 1988.

The occupational classiﬁcations used in the Occupational Employment
Survey, the principal source of data for the matrix, are consistent with the
standard occupational classiﬁcations used by all federal agencies that collect
data. They represent a balance between comprehensive coverage that pro-
vides quality data and the ability (and willingness) of employers to respond.
(Appendix C gives the current deﬁnitions used in hospitals.) These cate—
gories and deﬁnitions should be continually evaluated and modiﬁed, if
necessary, to portray the allied health work force accurately.

The other data source for examining the base year supply of workers is
membership data from allied health associations. For ﬁelds that are well
deﬁned and have a single route of entry, and in which the associations
represent a very large proportion of the ﬁeld (e.g., occupational therapy),
this source usually provides a good estimate. For many allied health ﬁelds,
however, association membership data are incomplete or nonexistent. (See
Appendix D for a discussion of the different sources of data on the supply
of workers for each ﬁeld.)

New Entrants

For ﬁelds in which the bachelor’s degree is the entry-level educational
requirement, there are two main sources of data. The US. Department of
Education collects historical data on degrees awarded by ﬁeld of study.
These data include the allied health ﬁelds of occupational therapy, physical
therapy, dental hygiene, medical record librarianship, medical laboratory
technologies, radiologic technologies, and speech pathology and audiology.
The Center for Education Statistics periodically makes projections of the
total number of bachelor’s degrees and the number of awards to men and
women. These projections are based on mathematical projections of his—
torical trends in college enrollment by different age groups. As discussed
earlier, the committee has projected new entrants from bachelor’s degree
programs in some ﬁelds by assuming that the ﬁeld’s share of bachelor’s
degrees in the years 1987 through 2000 will remain constant at the 1986
level.

The second principal source of data on new graduates is the bodies that
accredit education programs. CAHEA is the largest, representing 24 allied
health ﬁeld occupations in 1987. Others include the American Physical
Therapy Association and the American Speech—Language—Hearing As-
sociation. Estimates of the number of future new entrants to the various
ﬁelds can be extrapolated from historical ﬁgures on graduates. Individual
states can use data from their own higher education institutions.

MEASURING DEMAND AND SUPPLY 61

Other Inﬂows

The weakest links in projecting the future supply of allied health workers
are the data for estimating entrants from outside the labor force, from
other occupations, and from abroad (immigration). These inﬂows (and
mirroring outﬂows) are important short-run labor market adjustment
mechanisms. The BLS staff has made some headway by matching Current
Populaton Survey data and calculating inﬂows and outﬂows for the matched
observations (Eck, 1984). Yet for occupations with small numbers of work-
ers (such as many of the allied health ﬁelds), these estimates are based on
an extremely small number of observations. Estimating inﬂows and out-
ﬂows of workers is an area in which the professional associations could do
a great deal to improve the data. The Forum on Allied Health Data, with
the help of appropriate expert consultants, should give attention to this
serious data weakness.

CONCLUSIONS AND RECOMMENDATIONS

The committee found that available data for assessing the current supply
of allied health personnel are inadequate, and it suggests that efforts be
made to improve these data. The BLS employment (demand) projections
are quite valuable and, when used in conjunction with other data, are likely
to be the only available demand estimates that are comparable across fields.

The federal government has a responsibility to monitor the health care
work force and to inform participants in the health care labor market and
public policymakers of trends and developments. The work of the Bureaus
of Health Professions and Labor Statistics and the Center for Education
Statistics is to be commended and should be built upon. To improve the
data on allied health ﬁelds, the committee recommends that the secretary
of health and human services convene an interagency task force com-
posed of representatives from BLS, the Center for Education Statistics,
and other agencies that collect relevant data on the allied health work
force. This task force should work toward increasing the amount and
improving the quality of data needed to inform public policy decision
makers, health care managers, unions, prospective-students, and aca-
demic institutions about the allied health occupations.

Staff for the task force should be provided by the US. Public Health
Service focal point for allied health personnel that is recommended in
Chapter 5.

REFERENCES

Eck, A. 1984. New occupational separation data improve estimates of job replacement
needs. Monthly Labor Review 10723—10.

62 ALLIED HEALTH SERVICES

Goldstein, H. 1987. Projections of demand and supply in occupations. Paper prepared
for the Committee to Study the Role of Allied Health Personnel, Institute of Medicine.
November.

Hall, R. E. 1978. job vacancy statistics in the United States. Background paper no. 3.
Washington, DC: National Commission on Employment and Unemployment Statis-
tics. May.

Institute of Medicine. 1983. Nursing and Nursing Education: Public Policies and Private
Actions. Appendix 5, Projections of Registered Nurse Supply and Requirements.
Washington, DC: National Academy Press.

‘Iacoby, I. 1981. Physician manpower: CMENAC and afterwards. Public Health Reports
96(4):?95.

Saunders, N. C. 1987. Projections 2000: Economic projections to the year 2000. Monthly
Labor Review 110(9):11-18.

Silvestri, G. T., and Lukasiewicz, ]. M. 1987. Monthly Labor Review 110(9):46—63.

Sloan, F. 1975. The Geographic Distribution of Nurses and Public Policy. Washington,
DC: U.S. Government Printing Ofﬁce.

3

 

Forces and Trends in Personnel
Demand and Supply

CHAPTER 1 DESCRIBED 10 ALLIED HEALTH FIELDS. People working in
these ﬁelds have seen their roles evolve in response to such forces as
demographic change, disease patterns, ﬁnancing trends, structural changes
in the delivery system, and technological development. This chapter ex-
amines these and other forces to establish a context for Chapter 4, which
discusses demand and supply in individual allied health ﬁelds. Before con-
sidering each of the environmental pressures that projections of employ-
ment must take into account, the interaction of several forces in one allied
health ﬁeld—respiratory therapy—is illustrated.

RESPIRATORY THERAPY’S MOVE INTO THE HOME:
THE ROLE OF INTERACTIVE FORCES

Respiratory therapy’s move into the home is an example of how several
environmental forces acting together may affect the evolution of a health
care service. These forces may bring about a shift in the work site and can
affect the independence, earnings, and educational requirements of prac-
titioners.

As with other allied health services, some respiratory therapy services
have shifted from hospital-based to home-based delivery. Although respi-
ratory therapists have long provided oxygen to patients at home, only
recently have technologically advanced life-support systems (e.g., mechan-
ical ventilators) been widely used there. Several forces operating together
may have accelerated the trend toward home delivery of respiratory ther-
apy services. These forces include the following:

63

64 ALLIED HEALTH SERVICES

1. Demographic change As of 1984 approximately 28 million Americans,
or 11.9 percent of the population, were aged 65 or older; the over-75
group is now the fastest growing age segment of the population (Public
Health Service, Ofﬁce of Disease Prevention and Health Promotion, 1987).
The aging of the US. population can be Viewed in terms of its relationship
to disease prevalence: as the population ages, chronic diseases grow more
prevalent. It is estimated that over 3 million Medicare patients suffer from
chronic obstructive pulmonary diseases such as emphysema, chronic bron-
chitis, and asthma. Almost a quarter of a million others experience breath-
ing difﬁculties for reasons other than pulmonary disease (e.g., spinal cord
injuries). As many of these conditions progress, respiratory therapy be-
comes necessary.

2. Technological change Several innovations in technology have made
home-based respiratory care feasible and more acceptable to patients. For
instance, equipment has become smaller. Some microprocessor—controlled
ventilators and suction machines are compact enough to be mounted on
wheelchairs or specially designed carts, giving people who need the ma-
chines a measure of mobility.

3. Health care ﬁnancing policies Environmental forces are not always ex-
pansionary. Health care ﬁnancing policies, including pressures to cut health
care costs, may fuel the move to home care. On the other hand, ﬁnancing
policies may also be used to curtail an expansion of home care that is made
possible by new technologies.

Medicare’s prospective payment system is stimulating the need for re-
spiratory therapists outside the hospital. PPS gives hospitals a strong in—
centive to discharge all patients as quickly as possible, thereby reducing
hospital costs. Pulmonary patients, although well enough to be discharged,
are often in need of care at home. Yet Medicare does not reimburse the
home care services of respiratory therapists on a per-visit basis. Rather, the
cost of their services may be included as an administrative expense by
agencies providing home care services. Only 6 percent of home health
agencies retain a respiratory therapist. The rest occasionally consult with
therapists, contract with durable medical equipment services, or arrange
short-term training courses for their nurses assigned to pulmonary patients.
Respiratory therapists employed by suppliers of oxygen and other equip-
ment are reimbursed under Medicare’s durable equipment beneﬁt. In a
21-state survey, Gilmartin and Make (1986) found that Medicare and Med-
icaid were paying more than $270,000 per year for each ventilator-assisted
hospital patient. The association estimated that the cost for equivalent care
in the home would be $21,000 per year. Furthermore, it was estimated
that over 2,000 chronic ventilator-dependent hospital patients were well
enough to be cared for at home (Gilmartin and Make, 1986). The Health

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 55

Care Financing Administration argues, however, that expanding Medicare
coverage to include home-based respiratory care is likely to increase Med-
icare costs because it would be difﬁcult to limit specialized care to those
who truly need it (Health Care Financing Administration, 1986).

In sum, ﬁnancing policy has provided an impetus for respiratory home
care as well as impeded its growth. Improved technology (spurred by the
availability of ﬁnancing) has made respiratory home care feasible, and the
increasing number of elderly people in the population has heightened the
demand for such a service. The social value placed on independent living
has increased the marketability of delivering respiratory therapy services
in the home and has placed pressure on policymakers to expand insurance
beneﬁts to include home-delivered care.

The remainder of this chapter examines a number of separate forces to
determine how each impinges on the demand for and supply of allied
health personnel and to emphasize how an understanding of these forces
can help local decision makers interpret change in their own environment.

FORCES THAT DRIVE THE DEMAND FOR
ALLIED HEALTH PRACTITIONERS

Population Growth and Demographic Trends

Demographic trends provide clues about tomorrow’s health care con-
sumers and their health care needs. An analysis of the changes in the
composition and growth of the US. population shows how these trends
translate into changes in health care needs.

Population growth in the United States is slowing. The population in-
creased by 1 percent annually between 1972 and 1986, but the Bureau of
the Census projects growth of only 0.8 percent annually to the year 2000.
The rate of growth will not be uniform among age, race, or ethnic groups,
as shown in Table 3-1, which is based on the moderate projections of the
Bureau of the Census (Fullerton, 1987). Minority populations will grow
faster than the white population; the number of children and youths (with
the exception of high school youths) will decline; the working-age popu-
lation will grow twice as fast as the total population; and the number of
people of retirement age will increase with the greatest rate of growth
occurring among people aged 85 or older.

The Elderly

Between 1940 and 1984 the number of people aged 65 and older more
than tripled, growing from 9 to 28 million; this group is anticipated to
grow to 35 million, or 13 percent of the population, by the year 2000.

66 ALLIED HEALTH SERVICES

TABLE 3-1 US. Population (in millions) by Race and Age, 1986 and
Projected for the Year 2000

 

 

Percentage
1521:5253 u_____
Population 1986 2000 1986—2000 1986 2000
Total 241.6 268.3 11.1 100.0 100.0
White 204.7 221.5 8.2 84.7 82.6
Black 29.4 35.1 19.4 12.2 13.1
Asian and other 7.5 11.6 54.7 3.1 4.3
Hispanic 18.5 30.3 63.8 7.7 11.3
Age group
0—4 18.1 16.9 —6.6 7.5 6.3
5—13 34.2 33.5 —2.0 14.2 12.5
14—17 14.8 15.3 3.4 6.1 5.7
18—24 28.0 25.2 — 10.0 11.6 9.4
25—64 116.3 142.5 22.5 48.1 53.1
65—84 26.4 30.3 14.8 10.9 11.3
85 and older 2.8 4.6 64.3 1.2 1.7

 

SOURCE: Fullerton (1987).

While increases in the number and proportion of individuals over 65 have
been considerable, a faster rate of growth is evident in the very old segment
of the population. In 1950 there were just 600,000 people aged 85 or older;
by the year 2000 it is expected that number will have increased nearly
eightfold.

As the number of elderly people increases, the demand for allied health
practitioners in a variety of ﬁelds will rise accordingly. About 17 percent
of occupational therapists’ total practice in 1982 was service to the elderly
in nursing homes and acute care hospitals. Audiologists now spend one-
third of their time with older persons (National Institute on Aging, 1987).
Using straight-line projections and assuming that the mix and ratio of
personnel to patients will be the same in the year 2020 as they are today,
the National Institute on Aging estimates that twice as many occupational
and physical therapists will be needed in 2020 as are available today. It
also estimates that 40 percent more audiologists will be required to maintain
service at the current level (National Institute on Aging, 1987).

Children

Between 1980 and 1984 the number of school—age children fell by 2.5
million. During that same period, however, the under-5 population rose
9 percent to 17.8 million, the largest under-5 population since 1968, when
it was 17.9 million. The Census Bureau expects that there will be fewer
children under 5 (16.9 million) by the year 2000, and the number of

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 67

children as a whole (under 17 years old) will fall from 67.1 million in 1986
to 65.7 million in 2000 (Fullerton, 1987).

Children and adults use health care services differently. Children have
less need of acute care services and have fewer hospital days (National
Center for Health Statistics, 1986). A reduction in the number of children
in the population does not affect the demand for all allied health practi—
tioners. For those practitioners employed by schools (speech—language pa-
thologists, for example), the number of children in the population has a
noticeable impact on demand. For practitioners focused on acute care, the
impact, if any, is slight. Children are also major users of disease prevention
services, some of which employ allied health practitioners—for example,
dental hygienists in dental caries prevention. For practitioners in many
allied health ﬁelds, children represent only a small portion of their practice.

The implications for allied health practitioners of the predicted drop in
the number of children in the population must be balanced against the
effect of disease prevention efforts and the vigor with which such efforts
are being made.

The demand for those allied health personnel who are most central to
child health services (e.g., dental hygienists, speech—language pathologists
and audiologists) will depend to a great extent on public investment de-
cisions that are often made at the local level. Local funds are the sole source
of support for health education programs in 75 percent of all school dis-
tricts. About 20 percent of school health education programs receive state
funding; only 3 percent receive federal, private, or special funds for such
programs (Public Health Service, Ofﬁce of Disease Prevention and Health
Promotion, 1987).

Minorities

One out of ﬁve persons in the United States in 1986 was a member of
a minority group. Blacks, the largest group at 29.4 million, constituted 12.2
percent of the total population in 1986. By the year 2000, 35.1 million
blacks will constitute 13.1 percent of the population. The number of His-
panics is rising even more sharply. Hispanics totaled 9.1 million in 1970
and 18.5 million in 1986; they are expected to total 30.3 million people—
more than 11 percent of the population—in the year 2000. The number
of Asians and Paciﬁc Islanders in the United States is also growing rapidly.
Between 1970 and 1980 this population group grew 120 percent to 3.7
million. By the year 2000 it will total 11.6 million (Fullerton, 1987).

The prevalence of some diseases is higher among minorities than among
whites. Diabetes, for example, is far more prevalent among blacks than
among whites, and the incidence rate for cancer in 1983 was highest among
black males. Among native Americans, cirrhosis, pneumonia, and diabetes

68 ALLIED HEALTH SERVICES

are more common than among whites, and the prevalence of diabetes
among Mexican Americans is nearly twice that among whites (Public Health
Service, Ofﬁce of Disease Prevention and Health Promotion, 1987).

The changing proportion of the total minority population and the higher
prevalence of some diseases among the various groups in that population
may affect the demand for services as health care needs change. Factors
such as ﬁnancial and geographic access barriers also inﬂuence the demand
for health care services, however, and health care needs do not always
translate into a demand for services. Minorities are more likely than whites
to lack health care insurance, and they consistently report greater difﬁculty
than whites in gaining access to medical care. Twenty-six percent of His-
panics have no medical coverage compared with 9 percent of whites and
18 percent of blacks (Public Health Service, Ofﬁce of Disease Prevention
and Health Promotion, 1987).

These differences between whites and minorities in access to health care
are reﬂected in health care utilization rates. Twenty percent of blacks and
19 percent of Hispanics indicate they have no usual source of medical care,
compared with 13 percent of whites. Between 1978 and 1980 the per-
centage of people 4 to 16 years old who had never received dental care
was higher among Mexican Americans (30.7) than among blacks (22.3) or
whites (9.7). Similarly, the percentage of individuals with no physician
contact was higher among Mexican Americans (33.1) than among other
Hispanics (23.9), blacks (23.8), or whites (20.4) (Public Health Service, Of-
ﬁce of Disease Prevention and Health Promotion, 1987).

The expected increase in minority population groups by the year 2000
could have an effect on the need for allied health practitioner services. For
these needs to translate into effective demand, however, the current bar-
riers to care must be eliminated.

Disease Patterns

There are two changes in disease patterns within the United States that
deserve special attention because of their potential impact on allied health
personnel. First, there is the growing acquired immune deﬁciency syn-
drome (AIDS) epidemic. Second, whereas infectious diseases such as in—
ﬂuenza, smallpox, and tuberculosis were the leading causes of death at the
turn of the century, today chronic diseases predominate in this area.

Acquired Immune Deﬁciency Syndrome (AIDS)

AIDS is a notable and unexpected exception to the trend of declining
death rates from infectious disease. As of 1987 an estimated 1.5 million
Americans were infected with the human immunodeﬁciency virus, now

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 69

known to be the cause of AIDS. AIDS cases in the United States rose from
183 in 1981 to nearly 40,000 by the middle of 1987. Over 75 percent of
persons diagnosed with AIDS die within 2 years of the diagnosis.

As the disease spreads and the number of cases grows, and particularly
if the life expectancy of infected individuals lengthens with the discovery
of new treatments, the health care system will be increasingly taxed. In
1985, AIDS was the cause of 23,000 hospitalizations, an increase from the
estimated 10,000 of the year before. The average length of stay for an
AIDS patient was more than double the overall average of 6.5 days (Traf-
ford, 1987). The federal government estimates that it will spend $1 billion
on AIDS in ﬁscal year 1988, 40 percent of which will go to patient care.
The Health Resources and Services Administration (1988) estimated that
AIDS will account for $8 billion to $16 billion in direct medical care ex-
penditures in 1991.

Estimating the impact of AIDS on the demand for allied health personnel
is fraught with uncertainties. Greater precision in estimating needs and
workloads will come from a better understanding of some key determinants
of the disease. Epidemiologists can estimate only roughly the number of
individuals who are currently infected, as well as those who will develop
the full-blown symptoms of the disease.

The disease manifests itself in many forms, and treatment patterns vary.
The progression of the disease often resembles the chronic illnesses of old
age (e.g., dementia and wasting). AIDS patients therefore need some of
the same services as the elderly and may compete for scarce resources (e.g.,
skilled nursing care and home health services) (Health Resources and Ser-
vices Administration, 1988). The volume of acute care facility use for AIDS
care and treatment relative to that provided in community settings now
varies among localities. The introduction of new preventive, diagnostic,
and treatment modalities may alter the mix of personnel and settings of
care in ways that are now difﬁcult to predict. Methods of ﬁnancing care
may also play a role in determining the type and focus of AIDS care.

Some allied health ﬁelds already play a major role in addressing AIDS;
the role of others is still emerging. Clinical laboratory personnel are not
only conducting the tests used to detect the virus that causes the disease,
but they are also facing a heavier workload generated by the secondary
infections that AIDS patients often acquire. Occupational therapists are
helping AIDS patients learn how to conserve their energy, and respiratory
therapists are providing care to patients who develop lung infections. A
host of counselors is emerging to assist patients during the various stages
of the disease.

The committee noted growing concern about the effect of AIDS on the
supply of as well as the demand for allied health practitioners. Some ed-
ucators fear that potential allied health students may be dissuaded by their

70 ALLIED HEALTH SERVICES

perceived increased risk of exposure to the disease. To date, however,
there has been nothing beyond anecdotal evidence to indicate that this
perception is a serious factor in allied health career choices.

Chronic Diseases

Chronic conditions are the most prevalent health problem for the elderly,
and the proportion of elderly people in the US. population is increasing.
More than four out of ﬁve persons who are aged 65 and older have at
least one chronic condition, and multiple conditions are commonplace among
older persons (US. Senate, Special Committee on Aging, 1987).

The demand for allied health practitioners may be inﬂuenced both by
efforts to curtail the incidence of chronic disease and by medical successes
in treating chronic conditions. For example, some allied health ﬁelds are
directly affected by widespread efforts to reduce the risk factors for car—
diovascular disease. Clinical laboratory personnel are conducting more blood
tests and dieticians are providing more counseling in an effort to determine
and control cholesterol levels. Increased rates of survival in cases of stroke
and heart attacks may mean increased demand for health care because the
majority of patients do not make a full recovery (Public Health Service,
Ofﬁce of Disease Prevention and Health Promotion, 1987). Of the nearly
2 million stroke patients in the United States, 40 percent require special
services and 10 percent require total care. The results from a large, lon-
gitudinal study also indicated the need for care: when stroke survivors were
examined an average of 7 years after their stroke, 31 percent needed
assistance in self—care and 2.7 percent required help in ambulation (Public
Health Service, Ofﬁce of Disease Prevention and Health Promotion, 1987).

Economic Growth

The growth of the economy as a whole dictates how much income will
be generated and how this level of income will affect government spending
and the income that will be available for families to spend on health care
(and other kinds of consumption) and to save.

There are many uncertainties involved in projecting economic changes.
They range from the policies that will be adopted regarding taxes, gov—
ernment expenditures, foreign trade, and events such as wars and revo-
lutions, to scientiﬁc discoveries that affect technology, and even to the
weather, which may kill crops or create disasters. Making a projection entails
making assumptions as to how each of these uncertainties will affect eco-
nomic change. BLS, whose employment projections the committee used,
details a long list of such assumptions; from these, it calculates high, low,
and moderate projections to illustrate that there is a range of error around

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 71

any projection and to describe the sensitivity of the projections to these
variables.*

Personal income affects all kinds of expenditures, including health care
spending, in many ways. For instance, it influences what consumers are
willing to spend on health insurance. Consumers are also responsible for
about a quarter of total national health care expenditures through direct,
out-of-pocket payment for services (Health Care Finanacing Administra-
tion, 1987). Under BLS’s moderate scenario, real disposable income (i.e.,
income after taxes and before inﬂation) is expected to grow by 2.4 percent
annually (low projection, 0.7 percent; high projection, 1.9 percent), less
than the 2.7 percent average annual growth for the previous 14 years.
From this projection are derived the BLS projections of personal con-
sumption expenditures on services (of which health care services are a
part). The expenditures on services are expected to grow faster than total
personal consumption expenditures, as they have in the past: 3 percent
(low projection, 2.2 percent; high projection, 3.3 percent), compared with
the 3.2 percent average for 1972—1986.

Government spending is inﬂuenced by economic conditions. BLS pro-
jects higher levels of federal government spending in their high-growth
projection than in their low—growth projection. This factor is important for
health care employment because the federal government accounts for nearly
29 percent of national health care expenditures. BLS projects the Medicare
portion of federal health care expenditures in constant dollars. The increase
from the low projection in 1986 to that of the year 2000 is 30 percent; the
increase from the 1986 high projection to that of the year 2000 is 62
percent. Between the 1986 and year 2000 moderate projections, BLS pre-
dicts a 43 percent increase in expenditures. These differences could have
an effect on those allied health practitioners whose employment is signif-
icantly dependent on Medicare spending.

Private health insurance, which pays for more than 30 percent of national
health care expenditures, is affected by economic conditions in several ways.
For instance, the size of corporate profits can affect the richness of the
benefit packages and health insurance that employers offer employees.
Furthermore, the number of people covered by private insurance depends
in part on the unemployment rate, which in turn depends on economic
conditions. Because unemployed people often lack health insurance, in
times of high unemployment the demand for nonessential (and some es-
sential) care is reduced. In that case, health care employment will also be
reduced.

*Data for the discussion of the BLS economic projections that follows are drawn from
Saunders (1987).

72 ALLIED HEALTH SERVICES

Structure of the Health Care Industry

The structure and organization of health care services are constantly
evolving in response to such forces as the availability of money and human
resources, regulation, consumer demand, ﬁnancial incentives, and tech-
nology. Major changes in recent decades include the growth of multi-
hospital systems and investor-owned health care providers, the growth of
managed care, and the movement of care from inpatient settings into
outpatient departments, physicians’ ofﬁces, and specialized freestanding
centers. Figure 3-1 illustrates the decline in the hospital as the prime em-
ployment site for the health care industry. This decline reﬂects a structural
change: the hospital’s fall from its position of primacy in health care pro-
Vision.

Structural changes may or may not affect the delivery of health care
services and the demand for health care workers. Changes in the location
of a service may represent only a change in work site for allied health
personnel without altering the number of persons who are actually em-
ployed. For example, hospital admission testing today is often done on an
outpatient basis, and unless there is a change in the volume of tests per-
formed, there is no numerical employment signiﬁcance to the change in
the testing site. Although structural changes may not affect demand, they
could have an effect on educational requirements and regulation. Practi-

PERCENTAGE

 

1965 1968 1971 1974 1977 1980 1983 1986

CALENDAR YEAR
FIGURE 3-1 Hospital employment as a percentage of health care industry employment:
calendar years 1965—1986.

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 73

tioners may need new levels or arrays of skills in the new settings, and new
quality concerns may emerge that could result in changes in regulation.

Other changes in the structure of the health care industry have consid-
erable implications for allied health practitioner demand. For example, as
patient lengths of stay in a hospital become shorter, the need for home
care increases and more practitioners may be needed. To determine whether
a change in the location of care has implications for demand, one must
ask whether each allied health ﬁeld used in the traditional location is likely
to be used in the new setting, and whether the volume of service and
productivity will change.

The growth of HMOs has had no real impact on allied health employ—
ment to date. A 1987 survey of allied health employment in 56 HMOs that
included staff, group, and independent practice association models across
the country found that employment for most allied health ﬁelds was not
substantial. For example, 22 HMOs employed a total of 110 medical tech-
nologists, 26 HMOs employed 42 nutritionists, and 13 HMOs employed
34 physical therapists. Respondents stated that they did not expect to em-
ploy larger numbers of practitioners in the near future (Rudman et al.,
1987).

The formation of multihospital systems is important to allied health
employment if these systems staff their facilities differently than indepen-
dent hospitals. Studies that compare stafﬁng in different types of hospitals
have often focused on ownership characteristics such as public, private,
for-proﬁt, and not—for—proﬁt status (see, for example, Watt et al., 1986;
Mullner and Andes, 1985). Little is known about the differences in stafﬁng
between independent and multi-institutional facilities.

BLS has projected employment in the health care industry to the year
2000 (Personick, 1987). (See Appendix E for a detailed discussion of these
projections.) The projections take into account some of the stmctural changes
discussed in this section. Notably, BLS foresees that hospitals will increase
employment despite the shift to outpatient care. This trend is largely due
to the expected increase in the proportion of elderly people in the pop-
ulation and to advances in technology. Table 3-2 shows actual employment
in 1986 in ﬁve health care settings and the BLS projections to the year
2000. Outpatient facilities with an annual growth rate of 4.6 percent are
expected to show the highest growth rate and rank as the second fastest
growing industry in the economy in terms of employment. But because
the private hospital sector is so much larger, its 1 percent annual increase
will add almost as many jobs as the 4.6 percent growth of the outpatient
setting. The second fastest growing sector—ofﬁces of health practitioners—
reflects the growth of such activities as physicians’ ofﬁce labs, ofﬁce surgery,
and independent allied health practices. Nursing homes will also experience
rapid growth as the aged population grows and early discharge from hos-

74 ALLIED HEALTH SERVICES

TABLE 3-2 Wage and Salary Employment (in thousands) in Health
Care Services by Setting, 1986 Actual and Projected for the Year 2000

 

 

Annual
Actual, Projected, Increase

Setting 1986 2000 (percentage)
Health care services

excluding federal hospitals 7,599 10,844 2.6
Total private health care

services 6,551 9,774 2.9
Ofﬁces of physicians,

dentists, and other health

care practititioners 1,672 3,061 44
Nursing and personal care

facilities 1,250 2,097 3.8
Private hospitals 3,038 3,513 1.0
State and local hospitals 1,048 1,070 0.2

Outpatient facilities and
health care services not
cited elsewhere 591 1,103 4.6

SOURCE: Personik (1987).

 

pitals increases the demand for nursing home care. Thus, an additional
800,000 jobs will be generated by nursing and personal care homes by the
year 2000.

Health Care Financing

Health care expenditures in the United States are rising. In 1986 Amer-
icans spent an average of $1,837 per person on health care for a total of
$458 billion. This total constitutes 10.9 percent of the GNP, an increase
from 10.3 percent in 1984 and 5.9 percent in 1965. The Health Care
Financing Administration projects health care expenditures of $1.5 trillion
in the year 2000—the major payers being the federal government, which
will pay one-third; private insurance, which will pay 30 percent; and pa-
tients, who will pay one-quarter (Health Care Financing Administration,
1987). As health care payers look to the future, the picture is one of
increasing costs as the population ages and scientiﬁc advances make care
ever more complex.

It is difﬁcult to overstate the effect that ﬁnancing policy has on the
demand for allied health personnel. Two types of impact on employment
should be highlighted.

First, ﬁnancing incentives can change the way a health care provider
views allied health services. Whereas some services, such as laboratory ser-
vices, were considered to be revenue producing prior to the recent ﬁ-
nancing change to prospective pricing, they are now perceived as a cost

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 75

element in the health care product and thus ripe for management econ—
omizing efforts. Alternatively, the way health care services are reimbursed
can create incentives for the expansion of a service to which allied health
workers contribute. For example, the ability of a hospital to enter the sports
medicine market will depend on its ability to attract physical therapists.

Second, ﬁnancing policy also affects the ability of individual allied health
practitioners to prosper in the health care market. At issue in this case are
fee-for-service reimbursement and direct access to patients without phy—
sician referral. Tied to these issues are a set of regulatory concerns em-
bodied in licensure laws, such as scope of practice and supervision of
practitioners by other health professions. Respiratory therapists, for ex-
ample, are seeking to gain direct Medicare reimbursement for home ser-
vices so they can move from a consideration of their services as part of
home health agency overhead to marketing their own skills in a manner
not unlike that of occupational and physical therapists. Likewise, dental
hygienists are seeking to gain independence from dentists in their ability
to bill for services, a move requiring both licensure and reimbursement
accommodation.

Perhaps the most dramatic example of the importance of ﬁnancing in
generating demand for services and personnel is the spread of third—party
reimbursement in the 19605, a trend that generated increased demand for
services, an era of hospital building and technology adoption, and rising
employment for health care personnel. More recently, the federal govern-
ment has established a cost containment measure, the prospective payment
system (PPS), that shifts the risk of the cost to the provider. Under PPS,
hospitals are reimbursed on the basis of a preset per case payment, and
the level of payment depends on the diagnosis.

A number of observers have examined PPS’s initial impact on hospital
operations. Following initiation of the system, length of hospital stay de—
creased at a faster rate than had been occurring previously (although there
was a slight upturn in 1986), and occupancy has averaged only 66.6 percent
since 1983, when the phase-in of the program ﬁrst started. However, the
proportion of patients with complex problems has increased (Prospective
Payment Assessment Commission, 1987), and stafﬁng has been altered as
hospitals adapt to these changes. Hospital employment, which had been
increasing at a rate of 4.9 percent per year in the 6 years before prospective
payment, decreased in 1984 and 1985 (2.1 percent and 1.8 percent, re-
spectively) and increased only slightly (0.4 percent) in 1986 (Prospective
Payment Assessment Commission, 1987). Further analysis of hospital staff-
ing shows that the use of part-time employees has increased and for many
allied health ﬁelds there was a shift to employees with higher levels of
training. It is not clear whether the move to higher skill levels reﬂects the
needs of sicker patients or a perception that a more highly educated em—

76 ALLIED HEALTH SERVICES

ployee is a more cost-effective employee. The shift to part-time stafﬁng
could be a cost containment effort as well as a way to make ﬂexible stafﬁng
easier. For some allied health ﬁelds, it may simply reﬂect the difﬁculty of
hiring full-time staff. Alternatively, it may signal a move to policies that
are designed to minimize the cost of employee beneﬁts.

The Bureau of Health Professions (Health Resources and Services Ad-
ministration, U.S. Department of Health and Human Services) asked the
American Hospital Association to report stafﬁng changes since the intro-
duction of PPS. The following general trends were found:

0 increased emphasis on productivity;

0 heightened demand for employees who can work in more than one
functional area and thus decreased interest in professional credentialing
that restricts the practitioner’s scope of practice;

0 increased use of part-time employees, contract services, and ﬂoat pools;

0 increased competition among professionals;

0 replacement of personnel by capital;

0 fewer management positions; and

0 increased retraining and cross-training of personnel (American Hos-
pital Association, 1985).

A small study of 13 Philadelphia hospitals in 1985 provides some insight
into the personnel strategies of institutions that are adjusting to PPS. Most
of the hospitals surveyed had cut their labor force through attrition, pri-
marily in the ranks of less skilled patient care employees (Appelbaum and
Granrose, 1986).

More recent studies of PPS’ s impact on hospitals suggest that the down-
ward trend 1n stafﬁng has been reversed A 1987 national survey of lab-
oratories found that after sharp post-PPS staff and budget cuts, testing
volume 15 up, budgets are bigger, and staff reductions are abating. In 1986
only 16 percent of labs reported staff increases; a year later, 31 percent
were reporting staff increases (Core, 1987).

Another aspect of health care ﬁnancing—mandated beneﬁts—may also
inﬂuence the utilization of health care services. States mandate insurance
coverage to improve access to services. In the past two decades, 645 man-
dated coverage bills have been passed by the states (Scandlen, 1987). Cur-
rently, coverage is mandated for physical therapists in two states and for
speech and hearing therapists in four states (Scandlen and Larsen, 1987).
Some states mandate the coverage of all licensed health care practitioners.

Technological Change

The direction of technological change and its effect on allied health
employment are difﬁcult to predict. Some of the changes in health care
ﬁnancing and the structure of the delivery system suggest likely future

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 77

directions: health care managers appear to be interested in technologies
that will improve productivity and lower costs; technologies that enable
providers to establish organizations that ﬁll a special market niche are also
likely to be purchased.

Technological change is not only reactive (to such factors as ﬁnancial
incentives) but prospective as well; that is, it drives the type of care provided
by delivery systems. For instance, the technology of renal dialysis gave rise
to the creation of dialysis centers and to practitioners who specialize in
treating patients with end-stage renal disease. Technologies also drive the
organization of delivery systems. Electronic telemetry equipment, for ex-
ample, enables patients to be treated in nontraditional settings such as
satellite facilities, homes, and vehicles. How technologies that are as yet
underdeveloped will inﬂuence allied health employment is, of course, not
known. Seymour Perry, professor of medicine at Georgetown University
and former director of the National Center for Health Care Technology,
described the following advances at the workshop held by the committee
in April 1987:

0 Automation in clinical laboratories will progress, decreasing the com—
plexity of tasks and increasing productivity. It is anticipated that the only
category of lab personnel that may be replaced by computers is that com-
prising the least skilled. More highly trained individuals may actually be
in greater demand as computers are added to the laboratory.

0 Computer-based technologies will be used increasingly, especially for
clinical decision making, administration, medical recordkeeping, and pa-
tient monitoring.

0 Genetic and monoclonal antibody technologies will generate new di-
agnostic tests. Many monoclonal antibody-based diagnostic tests will be self-
administered in the future, and new test reagents will replace more labor
intensive tests such as culturing. The early diagnosis and monitoring of
tumors permitted by these technologies will change treatment modes and
prognoses for numerous cancers.

0 Advances in technology will permit more health care to be delivered
in outpatient settings. The development of less invasive surgical technol-
ogies will spur outpatient surgery. As new generations of laboratory and
diagnostic imaging equipment become smaller, more diagnostic procedures
will be performed in physicians’ ofﬁces and other nonhospital sites. Other
technologies, such as programmable infusion pumps for pain medication
or chemotherapy, will shorten hospitalization and allow for home care of
patients.

New technologies that emerge from basic science and that represent real
advances in diagnosis and treatment are likely to be adopted. Yet initially,
the effectiveness of such technologies is not always clear; hence, there is

78 ALLIED HEALTH SERVICES

growing interest in technology assessment. In addition, it is not always clear
how technological change will affect human resources, especially in the
long run.

The development and adoption of new technologies follow various paths
and have differing effects on the demand for allied health personnel. Along
one path, for example, a new technology initially requires highly skilled
personnel and is of low productivity until it becomes a routine procedure
that can be performed in high volumes by lower level staff. In the path
typically taken by laboratory tests, the test becomes automated. Other tech-
nologies may use personnel differently.

The relationship between human resources needs and technological change
ﬂuctuates constantly but is seldom explored, making it difficult to assess
the future with much certainty. Although we have some understanding of
the forces that drive technological change, the effects of such change on
allied health practitioners have not been adequately researched.

The Supply of Other Health Practitioners

The supply of other health practitioners—doctors, nurses, dentists—
inﬂuences the demand for allied health services in several ways. As the
supply of physicians continues to grow at a rapid pace (over 50 percent
growth is expected between 1980 and the year 2000), allied health prac-
titioners must ask whether physicians whose practices fail to bring the
income they desire will seek to take back functions they had delegated to
allied health practitioners in earlier periods. Physicians also wonder about
this. One surgeon wrote:

To abrogate one’s responsibility for postoperative care is retrogressive and tends
to return to the period of 200 years ago, when the surgeon was simply a technician.
I do not believe that only the respiratory therapists can understand the controls of
the MA2 or Bear respirators. I do not believe that the surgeon who operates upon
the intestinal tract should need an enterostomal therapist to take care of the prob-
lems in a patient with an ileostomy. I do not believe that the surgeon who performs
a mastectomy should require a physical therapist to assure that the patient has
normal arm motion following this operation. Gordan, 1985)

Since the Graduate Medical Education National Advisory Committee
(GMENAC) made its prediction in the 19705 of a surplus of 70,000 phy-
sicians by 1990, there has been considerable debate in the literature about
whether these numbers are in excess of an “optimal” level and, if there
were, indeed, an excess of physicians by 1990, what that could mean for
the health care system. GMENAC concluded that nonphysician providers
(that is, physician assistants, nurse practitioners, and nurse-midwives) may
substitute for physician services and thus aggravate the physician surplus
(GMENAC, 1980). Some allied health leaders have been concerned that
this conclusion has been generalized inappropriately to all allied fields.

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 79

For physicians to assume what are now considered to be allied health
functions, at least three conditions must be satisﬁed:

1. Physicians must be willing once again to take on tasks that the
medical profession had delegated to less highly skilled providers because
these tasks were considered repetitive or unchallenging.

2. Physicians must be competent to perform the tasks. While in theory
the medical doctor license permits the physician to perform most of the
tasks of allied health practitioners, in many cases their training has not
prepared them to function effectively or productively in the full range of
services of many of the allied health ﬁelds.

3. Payers and managers must be willing to recompense the cost of the
substitution. The decision to substitute physician time for the time of the
allied health practitioner must make economic sense to the physician or
the organization that employs the physician. In a physician’s office this
substitution implies that physician time is so underutilized that it is pref-
erable to use a physician to do the tasks rather than pay an allied health
practitioner to do them. In an organization that employs physicians, for
example, an HMO, such substitutions mean that physician and allied health
personnel salaries are so nearly equal that allied health practitioners are
not worth employing because of their more limited scope of practice and
sometimes more limited patient appeal.

Competition between physicians and allied health practitioners is most
likely to occur when allied health practitioners are increasing their auton-
omy. For example, although physical therapists, physicians, and chiro-
practors offer the same service, in some senses they can be viewed as
competing for the first contact with patients having musculoskeletal pain
symptoms. The American Physical Therapy Association views competition
in the following light:

Members of the American Physical Therapy Association are actively seeking leg-
islative removal of the requirement for referral, that is, legislative provision for
direct access to their services, and have succeeded to date in 14 states (evaluation
with referral is permitted in another 22 states). This is an effort toward indepen-
dence in practice that does not put the physical therapist in direct competition with
the physician, and may, in fact, increase referrals to physicians in appropriate
circumstances. This is not to say that competition is lacking between physical ther-
apists and physicians. Such competition as does exist between these two practitioners
is competition between their businesses, not between the services that each person-
ally provides to patients. In recent years, physicians have increasingly employed
physical therapists in their businesses and compete directly with the businesses of
self-employed physical therapists and, in some instances, with the businesses of
hospitals which have a variety of out-patient and “outreach” physical therapy units.
(American Physical Therapy Association, 1987)

Medical technologists who are attempting to move more forcefully into
roles as directors of full—service laboratories are raising issues involving

80 ALLIED HEALTH SERVICES

“arbitrary barriers” that are being imposed by facility accreditation stan—.
dards. Competition may come from physicians who are reportedly seeking
a greater involvement in the laboratory business, and, to the extent that
physicians’ ofﬁce laboratories substitute for other testing sites, the use of
medical assistants and on-the-job trained personnel to run ofﬁce laboratory
equipment may be seen as a form of physician substitution and competition.

Anecdotally, there appears to be growing evidence of competition and
“turf” disputes between nurses and allied health personnel. At the com-
mittee’s public hearing (Washington, D.C., july 1, 1987), the Association
of Surgical Technologists spoke about their controversy over the operating
room sphere and whether they or nurses will perform certain functions.
Future nurse—allied health practitioner confrontations will in part be de-
termined by the supply of nurses and by whether managers will begin to
limit the breadth of nursing duties. On the other hand, nursing appears
to be moving up the ranks of faculty leadership into higher levels of decision
making about whether nurses or others will perform certain roles.

Counterbalancing the possible direct competition to allied health prac-
titioners from growing numbers of physicians is the positive effect of the
volume of work that may well be generated by their increased supply.
Utilization management techniques are geared to controlling the unnec-
essary use of services, but it is unclear how effective these tools will be in
reducing the volume of ancillary services and how this in turn will affect
allied health employment. Moreover, the continuing specter of malpractice
militates against vigorous efforts to control testing. A far-reaching response
to physicians who protect themselves against liability by practicing defensive
medicine does not appear to be imminent.

The net effect of the growing physician supply weighs more heavily on
the side of increasing rather than decreasing the services delivered by allied
health personnel. That is not to say that turf issues between allied health
' practitioners and others will lessen, but it appears that demand for allied
health personnel will not be unfavorably affected.

FORCES THAT DRIVE THE SUPPLY OF
ALLIED HEALTH PRACTITIONERS

The discussion thus far has focused on the factors that drive the demand
for allied health practitioners. In this section, we turn to forces that shape
the supply of allied health personnel.

The US. Labor Force

The future availability of allied health workers cannot be divorced from
larger trends in the US. labor force. The labor force is growing more
slowly than in the past, and the participation rates of various groups within

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 81

TABLE 3-3 Projected Changes in the US. Labor Force Between 1986
and the Year 2000 by Age, Sex, and Race

 

gifsgéage Percentage Distribution

Worker Group 1986—2000 1986 2000
Total workers aged 16 and older 17.8 100.0 100.0
Men

16 and older 11.8 55.5 52.7

16—24 —6.1 10.4 8.3

25—54 19.4 37.7 38.2

55 and older — 1.8 7.4 6.2
Women

16 and older 25.2 44.5 47.3

16—24 0.1 9.4 8.0

25—54 35.8 29.8 34.4

55 and older 10.1 5.2 4.9
Race

Whites aged 16 and older 14.6 86.4 84.1

Blacks aged 16 and older 28.8 10.8 11.8

Asians and other groups aged 16

and older 71.2 2.8 4.1
Ethnicity

Hispanics aged 16 and older 74.4 6.9 10.2

 

SOURCE: Fullerton (1987).

it is changing. The labor force is becoming older; it also includes more
women and more racial and ethnic minorities than in the past (Table
3-3).* .

The number of women in the labor force is projected to increase more
than twice as fast as the number of men, and in the year 2000 women will
constitute nearly half the labor force. They will also account for 63 percent
of the additional workers filling new jobs. Men and women of prime work-
ing age—that is, between the ages of 25 and 54—will be the most rapidly
increasing group, while the number of younger workers will decline. The
proportion of workers of prime working age will increase from 67.5 percent
in 1986 to 72.6 percent in the year 2000. The number of black workers
will increase twice as fast, Asian workers will increase five times as fast, and
Hispanic workers more than five times as fast as the number of white
workers. Hispanic workers will make up 29 percent of the workers entering
the labor market between 1986 and the year 2000; other minority groups
combined will constitute another 29 percent. Thus, by the year 2000 the
economy will be more dependent on women workers (who have always
been prominent in the allied health professions) and on minority workers.

*The discussion of the labor force that follows is based on data in Saunders (1987).

82 ALLIED HEALTH SERVICES

Trends in College Enrollment

In the majority of the allied health occupations, graduation from 4-year
or 2-year college programs is the way workers qualify for employment. We
must therefore examine trends in higher education enrollments and grad—
uations as a first step in estimating the potential labor supply of allied
health personnel.*

The college-age population—those people aged 18 to 24—is declining
as a result of a decrease in births two decades ago. After peaking in the
1980—1982 period, this population had dropped 8 percent by 1986; it is
expected to continue declining through 1996 when it will be 23 percent
below the 1980—1982 peak. The number of college-age people will then
begin to rise again, and by the year 2000 it is projected to be 6 percent
above the 1996 low point but still 19 percent lower than the 1980 peak
and about 12 percent lower than in 1986 (Figure 3-2). The resulting con-
striction in the ﬂow of new workers into the labor force will affect all
occupations. Whether it will affect the professions and other occupations
that require college education as much as it affects those occupations that
do not require college education depends on whether college attendance
declines as much as the size of the population. College enrollments and
graduations will maintain their current levels, or increase, only if a higher
proportion of youths go on to college.

Workers in the allied health ﬁelds are primarily women. There are a
few ﬁelds—emergency medical services, for example—in which women
constitute a small minority; in a few others, such as respiratory therapy,
the share of men and women in the work force is roughly equal. For the
most part, however, women predominate in the allied health ﬁelds. For
this reason, we focus on women’s college participation rates and on the
trends in women’s choices of ﬁelds of study.

The number of women receiving bachelor’s degrees increased steadily
between 1970 and 1986, reaching 502,000 in the latter year (47 percent
more than in 1970), as a rising proportion of college-age women completed
college. The Center for Education Statistics projects a further increase in
the number of women earning bachelor’s degrees that will peak at 512,000
by 1989, followed by a slow decline through the year 2000 to 470,000
graduates—about 6 percent below the 1986 level. Because the size of the
college-age population is expected to be 12 percent smaller than the 1986

*The following assessment uses data from the Census Bureau’s Current Population Surveys
and data developed by the U.S. Department of Education’s Center for Education Statistics
(National Center for Education Statistics, 1985; Center for Education Statistics, 1970—1987,
1987; D. E. Gerald, U.S. Department of Education, personal communication, 1988).

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 83

32

 

28—
24L
20—
16—

12-

POPULATION (millions)

     

 

 

     

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000

YEAR
FIGURE 3-2 College—age population (18 to 24 years): Actual, 1980—1982, and projected,
1983—2000.

population by the year 2000, this projection of female graduates assumes
that the proportion of women completing college will continue to increase.

Since these projections were made, the Center for Education Statistics
has released preliminary data for 1987 (based on a sample of colleges).
These data indicate an increase in the number of graduates between 1986
and 1987 instead of the decrease that had been projected. The preliminary
estimate of female baccalaureate degree graduates for 1987 was 512,000—
2 percent above the 1986 ﬁgure instead of 1 percent below it, as had been
projected. This increase may mean that the rising trend in the proportion
of women completing college is continuing even more strongly than earlier
estimates had assumed.

Graduations from programs that required fewer than 4 years of study
increased more rapidly than all other awards granted by institutions of
higher education from 1975 to 1985. Associate degrees awarded increased
by 26 percent. Whereas the increase in men earning associate degrees was
only 6 percent, almost 50 percent more women earned associate degrees
in 1985 than had earned them a decade earlier. Other degrees awarded
for programs of less than 4 years increased by 45 percent between 1975
and 1985.

There was a decline in the number of associate degrees awarded between
1985 and 1986 that is projected to continue through 1996, when the num-
ber of graduates will be about 11 percent fewer than in 1985. The Center

84 ALLIED HEALTH SERVICES

for Education Statistics does not make sex—speciﬁc projections for associate
degrees, but if current trends continue in the relative shares of degrees
awarded to men and women, we may expect that the decrease in female
associate degree graduates will be less than 11 percent. The number of
associate degree graduates is expected to resume its upward climb in 1997,
but in the year 2000 it will still be 8 percent below the 1985 level.

The Center for Education Statistics’ 1972, 1977, 1982, and preliminary
1986 data show no trend toward increased college enrollment among peo-
ple aged 25 to 44.

Trends in Women’s Choices of Fields of Study

The proportion of female baccalaureate graduates who enter health
ﬁelds (i.e.‘, allied health, health sciences, and nursing) has increased over
the past decade and a half. In 1970 slightly less than 5 percent of female
baccalaureate graduates chose these ﬁelds. This proportion increased to
about 11.5 percent in 1980; in 1986 it was just below 11 percent. Thus, at
a time when the number of women bachelor degree graduates was in-
creasing, the health ﬁelds nearly doubled their share of that rising total.
Together, the ﬁelds of business and management, communications and
communication technologies, computer sciences, and engineering did even
better. Their share of female graduates increased approximately 11-fold—
from less than 3 percent in 1970 to more than 32 percent in 1986. Yet the
gains in the ﬁelds of health, business, and communications were at the
expense of education. Education’s share of female graduates declined from
about 36 percent in 1970 to 13 percent in 1986, indicating a major change
in women’s career goals. The ﬁelds of psychology and the social sciences
attracted gradually declining shares of graduates over the 16-year period,
falling from 21 to 14 percent (Figure 3-3).

Among women earning associate degrees between 1983 and 1985, busi-
ness and management was also the top-ranking ﬁeld, followed by the health
sciences. For men, the health sciences were not among the three top-
ranking ﬁelds during these years.

Trends in the choice of study area within the health ﬁelds provide ad-
ditional information to estimate the potential labor supply of allied health
personnel. Nursing still accounts for almost 60 percent of the bachelor’s
degrees in the health ﬁelds that are awarded to women, although this ﬁgure
has fallen slightly since 1970 (Figure 3-4). Hospital and health care ad-
ministration, once the domain of men, has become increasingly attractive
to women. For physical therapy, occupational therapy, and speech—lan-
guage pathology and audiology, ﬁelds that require at least a bachelor’s
degree for entry, the number of graduates has grown over the years, but
their relative shares of health degree awards have remained constant. Nurs-

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 85

       

 

 

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1970 71 72 73 74 75 76 77 78 79 80 81 82 83 84 851986
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Business and Management/ - Computer Sciences/ m Social Sciences/
Communication and Engineering Psychology
Communication Technologies
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Health Sciences

FIGURE 3-3 Women earning bachelor’s degrees: Relative shares of selected major fields
of study, 1970—1986.

ing also dominates the degree awards for programs that require fewer than
4 years of study, accounting for about 52 percent of these degrees in recent
years.

For some fields, colleges are not the primary sponsors of CAHEA-ac-
credited educational programs. Programs in radiography, for example, are
based primarily in hospitals rather than in educational institutions. Con-
sequently the Center for Education Statistics data just cited include only
degrees and awards granted by institutions of higher education; they do
not encompass all allied health program graduates. Nevertheless, the im-
pact of non-college education programs on the validity of the trends por-
trayed by the data is marginal. Although noncollege sponsors accounted
for 40 percent of all CAHEA-accredited programs in 1986, they accounted
for only 33 percent of the graduates during the 1985—1986 academic year.

One of the factors inﬂuencing career choice is student perception of
employment opportunities. The BLS expects the number of jobs in some
of the ﬁelds that are currently popular with women (teaching, psychology,
social work, and, surprisingly, most of the business executive occupations)
to grow more slowly than the allied health ﬁelds in the coming years.

86 ALLIED HEALTH SERVICES

100

 

CUMULATIVE PERCENTAGE

     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1970 1972 1974 1976 1978 1980 1982 1984 1986
YEAR

Nursing - Occupational - Physical Medical Laboratory
Therapy Therapy Technologies

FIGURE 3-4 Relative shares of selected health ﬁelds, Women baccalaureates in allied
health and health sciences: 1970—1986.

Accounting and nursing are expected to grow at roughly the same rate as
the allied health ﬁelds. Employment in a few ﬁelds, including computer
sciences, is projected to grow at a faster rate than employment in the allied
health ﬁelds. To the extent that these expectations affect students’ choices
of careers, the allied health ﬁelds may be able to hold their own or even
gain a larger share of female college graduates. Because the number of
female college graduates is projected to remain at close to current levels
or to decline only slightly over the next 12 years, the supply of graduates
in the allied health ﬁelds may remain at close to current levels through the
year 2000, despite the decline in the college-age population.

Education Financing

A commonly cited maxim among allied health leaders relates to the
position of allied health in the pecking order of health professions edu-
cation programs: “Allied health ﬁelds are the last to be funded in good
times, the ﬁrst to be cut when resources are reduced.” This statement
reﬂects the importance of the economic climate in which higher education
resource allocation takes place and how decisions about allied health ed-
ucation resources are related to broader ﬁnancing trends. Education ﬁ-

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 87

nancing, the efﬁciency of education programs, and higher education’s
perceived contribution to society all have an impact on the longevity of
allied health education programs and future supply of allied health per—
sonnel.

Overall, national higher education expenditures in the past 10 years have
grown. Between 1973—1974 and 1983—1984 current funds expenditures,
adjusted for inﬂation, increased 23 percent for public institutions and 31
percent for private institutions. Much of that growth came in the mid-
19705. Public college spending in the latter half of the 10-year period grew
by only 5 percent; private college spending grew by 13 percent (Center
for Education Statistics, 1986).

There were shifts in revenue sources between 1973 and 1983. For public
institutions the federal share of total revenue decreased from 12.8 percent
to 10.5 percent; the state share remained relatively stable. For private
colleges the percentage of total revenue attributable to federal sources rose
slightly to 19.4 percent by the middle of the period but dipped to 15.7
percent by 1983—1984. State and local appropriations were relatively low
and declined slightly over the 10 years—from 3.2 percent to 2.5 percent.
Both public and private institutions that own hospitals have seen revenues
from their hospitals increase from 5.1 percent to 7.4 percent for public
colleges and from 8.7 percent to 10.1 percent for private schools. Private
institutions rely more heavily on tuition than do public schools (39 percent
compared with 15 percent), but the contribution of tuition is increasing in
both types of schools (Center for Education Statistics, 1987).

Although they fare better than most arts and sciences programs in gar-
nering external funding, allied health programs are nonetheless relative
newcomers to academia. As federal support has diminished, allied health
program administrators have become pessimistic about their place in higher
education institutions relative to traditional departments (e.g., history and
mathematics) and professional programs (e.g., engineering, medicine, and
business administration).

Federal funds to stimulate allied health education program development
peaked in 1974 at nearly $30 million and diminished substantially there-
after. No data are available on aggregate allied health education expen—
ditures, but much of the cost is borne by state and local government
expenditures and by tuition support in private institutions. The key driving
forces behind allied health education ﬁnancing are state and local appro-
priations, student demand, and the availability of clinical facilities and teach-
ing staff. Allied health education programs are vulnerable in each of these
areas (see Chapter 5).

Although there is variability among the states in the generosity of their
educational funding, cutbacks often mean that allied health programs,
because they are perceived to be expensive, are especially vulnerable. For

88 ALLIED HEALTH SERVICES

some allied health ﬁelds, this vulnerability is compounded by falling student
enrollments. Unlike other types of curricula, allied health education is
dependent on clinical facilities for teaching resources and is therefore af-
fected by health care ﬁnancing policy as well as higher education budgets.

State legislators and higher education ofﬁcials faced with difficult re-
source allocation decisions are seeking ways to ensure greater accountability
from collegiate institutions. For example, a Michigan commission on the
future of higher education in that state recommended various measures
to attain a “stronger, leaner, more efﬁcient system” and save on capital and
operating costs. These measures focused on the review of “non-core” and
“low-degree producing” undergraduate programs, health care profession
programs, high-cost programs, and programs with excess capacity because
of their geographic location (McKinney, 1986).

State ofﬁcials are also paying close attention to the products of the higher
education system and its impact on local economic development. Respon-
dents to a 50—state survey revealed that formal assessment of student and
institutional performance is a growing trend and is likely to intensify in
the years ahead. Among the broad array of activities evaluated by outcome
assessment are graduates’ employment experiences, their evaluations of the
education they received, employer hiring patterns, and former students’
job performance. Counterbalancing this orientation toward jobs is a grow-
ing concern that technically trained individuals be creative, have the ca-
pacity for civic responsibility, and receive a liberal education. Specialized
accrediting bodies for the professions are the continual targets of exhor-
tations to foster curricula that include general education in the humanities,
the arts, and the social sciences (Boyer et al., 1987).

Although most allied health programs report good initial job opportun-
ities for their graduates, this advantage in terms of outcome assessment is
balanced against the liabilities of unﬁlled student spaces, the need for
expensive equipment and high faculty/student ratios, and an image in some
academic circles as lacking in scholarly attributes.

Other Forces Inﬂuencing Supply
Unions

We noted earlier that the ability of the allied health ﬁelds to attract
students depends in part on the attractiveness of allied health occupations
relative to other occupations open to women. The ease with which a grad—
uate can ﬁnd work and the earnings that can be expected for that work
are both facets of the perceived attractiveness of an occupation. One factor
that affects both an occupation’s earnings and the kind of work life it offers
is the extent to which unions are present and active.

In many ﬁelds, unions help to determine demand and supply. Demand
is affected by collective bargaining agreements concerning such issues as

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 89

the length of the working day, the tasks that may be performed, and
compensation. Supply is affected by altered pay, beneﬁts, working hours,
job security, and other factors that make an occupation more or less at-
tractive to workers.

In recent years, unions have viewed health care, with its many unor-
ganized workers, as a major opportunity for expansion. In the past the
union movement has not had much success with health care workers. Its
limited success has been in the public sector and then only in some areas
of the nation. This situation has changed recently. Although union activity
in the private sector as a whole declined from 23 percent to 18 percent
between 1980 and 1985, union membership among health care workers
increased by 6 percent to about 20 percent of the health care work force
(American Hospital Association, 1986). In general, allied health occupations
appear to be covered less frequently by labor—management contracts than
are nurses, for example. In private hospitals in 23 metropolitan areas, 26
percent of nurses were covered, compared with 5 to 12 percent of occu-
pational, speech, and physical therapists, medical record administrators,
and dieticians. Approximately 20 percent of medical laboratory technicians
were covered, as were 16 percent of radiographers (American Hospital
Association, 1986).

Unions have not yet become a major factor in many allied health ﬁelds,
but service workers have become, with some success, the focus of much
union activity. The recent swing away from an emphasis on direct economic
considerations that nursing unions are exhibiting may provide some clues
about the concerns of other health care workers and suggest what may be
done to make employment in these ﬁelds more attractive.

Malpractice Litigation

The supply of allied health practitioners in some ﬁelds is also vulnerable
to the impact of malpractice litigation. Since the late 19605 the number of
medical malpractice claims and the size of jury awards have soared. By the
mid—19705 physicians in several states were having difﬁculty purchasing
malpractice insurance as insurers withdrew from the market; some phy—
sicians could not buy insurance at any price. For all physicians the average
cost of insurance increased by 81 percent between 1982 and 1985 (Health
Care Financing Administration, 1987). Malpractice litigation raises ques-
tions about quality, liability, and other issues. The experience of physicians
in this regard suggests how the supply of some allied health practitioners
potentially could be affected by malpractice litigation and insurance. Twenty—
one percent of respondents to a 1984 survey by the American Academy
of Family Physicians reported that they had restricted their obstetrics prac-
tice because of high premium costs. Thirty-ﬁve percent of respondents to
a survey by the American College of Obstetricians and Gynecologists said

90 ALLIED HEALTH SERVICES

that they had responded to professional liability risks by altering their
practice—reducing or eliminating the obstetrical component or eliminating
care for high-risk pregnancies (US Department of Health and Human
Services, 1987).

The supply of allied health practitioners whose autonomy of practice is
limited is unlikely to be affected by malpractice considerations. But for
some allied health ﬁelds, these considerations could, in the future, become
an important issue. The extent of physician supervision of an allied health
practitioner’s work can determine the practitioner’s legal responsibilities.
For example, if a physical therapist is the primary manager of a patient,
the therapist is responsible for assuming that appropriate informed consent
procedures are followed (Banja and Wolf, 1987). A 1982 case brought
against an audiologist in the California Supreme Court (Turpin v. Sortini et
al., 643 P. 2d 954) reveals the vulnerability of practitioners to malpractice
litigation even when the possibility of harm seems remote. In this case an
audiologist’s failure to diagnose deafness in a child was claimed to have
damaged a child born subsequently to the parents who, because it had not
been diagnosed, were not informed of the inheritability of the defect.

How the physician supply has been affected by malpractice issues can
be studied to good effect by those concerned with the future supply of
allied health practitioners. If practitioners successfully push toward modes
of practice in which supervision diminishes and autonomy increases, mal-
practice litigation and the cost of insurance could eventually limit the supply
of practitioners to those who are willing to endure the stress of litigation
threats and who have the resources to pay high premiums.

ALTERNATIVE PATTERNS FOR DEVELOPMENT OF
HEALTH CARE SERVICES: THREE SCENARIOS

It is obvious from the discussion thus far that there are many forces that
affect health care services delivery and the demand for and supply of allied
health personnel. It is virtually impossible to consider all of the elements
of these forces in attempts to evaluate the future for any single allied health
ﬁeld. Instead, the committee developed alternative assumptions about the
major factors that influence employment in the health industry. It believes
that looking at a limited number of broad scenarios is a useful tool for
decision makers trying to evaluate the future of speciﬁc allied health profes—
sions.

BLS’s employment projections are based on macroeconomic factors—
the trade balance, employment rates, productivity, and overall demand (see
Appendix E). Although demand for health care services and allied health
practitioners is related to macroeconomic growth, there are other forces
at work that may operate independently of these factors and in some cases

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 91

overwhelm them. Thus, the committee offers three simple scenarios that
are driven by the single force most likely to determine the size and direction
of change in health care services—health care financing. Unfolding events
can be considered in the context of these scenarios; decision makers con—
cerned with balancing demand and supply can apply the scenarios to es-
timate the demand side of the equation.

The three scenarios are based on health care ﬁnancing for two reasons.
First, financing is the major force shaping technology development and
adoption, the structure of the industry, and other determinants of allied
health personnel demand. Second, health care ﬁnancing responds, through
public and private policy decisions, to other important influences such as
the economy, demographics, disease patterns, and social values. Thus, fi-
nancing responds to some important determinants of demand and drives
others.

Scenario 1: The Mixed Model

The mixed model assumes a continuation of the existing mixture of
methods of payment. Selected services, both inpatient and outpatient, would
be paid on a prospective basis (using capitation, diagnosis, or some other
unit of payment); other services would be charged on a retrospective, fee—
for-service basis. Within the fee-for-service sector, some payers would ne—
gotiate rates with providers, whereas other payers would pay on the basis
of customary and reasonable charges. First-dollar coverage would be less
usual than the use of copayments and deductibles as utilization controls.

Other assumptions of the model include an increase in the proportion
of the population in managed care systems, which is projected to grow
steadily from today’s approximately 10 percent. The model also assumes
that hospital utilization by younger patients would continue to drop, but
upward pressure from the aging population would overwhelm any down-
ward trends and cause overall hospital admissions to rise slowly. The in-
tensity of care would continue to increase, as would selectivity in hospitalizing
young people and the number of admissions of older patients with complex
problems. Hospitals would continue their vertical integration as they sought
to retain their share of the market.

Under this scenario, non-inpatient services would increase, especially in
freestanding centers, the home, hospices, hospital outpatient departments,
and the like. Some long-term care would take place at home, but modest
expansion in the supply of nursing home beds would allow nursing homes
to continue as the chief long-term care institutional site. However, efforts
would be made to moderate the growth of nursing home beds to contain
costs.

Technologies that appeared to be cost—effective would be adopted rel-
atively quickly and diffused throughout the health care system. Technol—

92 ALLIED HEALTH SERVICES

ogies that promised to improve patient care outcomes would also be sought,
as would advances that allowed procedures to be performed on an out-
patient basis.

Scenario 2: Prospective Payment

This scenario assumes that prospective payment would become the dom-
inant payment mechanism, with not only hospital care but also most other
sorts of care paid on that basis. Generally, payment would be established
at a preset, negotiated level that was determined on a capitated or diagnosis
basis. Under this scenario, HMOs and preferred provider organizations
(PPOs), owned and run by insurance companies, would gain a substantial
share of the market. Indemnity insurance would be expensive and infre-
quently used. Large organizations of employers would become sophisti—
cated bargainers to successfully control health benefit costs through
negotiations with insurance companies and HMOs. Those organizations in
turn would bear the risks and thus would be impelled to exercise strict
utilization control and case management and become skillful at payment
negotiation to ensure their proﬁts. The number of salaried physicians
would increase substantially.

Hospital utilization would be affected by the growth of HMOs and other
managed care systems that were successful in controlling admissions. Al-
though the upward pressures of the aging population would be felt, under
this scenario, those pressures would not be sufﬁcient to prevent a small
drop in overall hospital utilization. Because hospitalized patients would be
more seriously ill, care would be more complex. Within the hospital, there
would be great emphasis on employee productivity and ensuring that un-
necessary or ineffective services were eliminated.

Outpatient and other cost-restraining delivery styles would increase rap-
idly with this scenario. Physicians who were not employed by managed care
systems would broaden the scope of their practices, supplying an increasing
range of services. All existing outpatient services would burgeon, and new
ones would be added as technology and entrepreneurial providers took
advantage of opportunities.

Technologies that were seen to be cost effective would be eagerly sought;
other technologies would be viewed more skeptically. However, the in-
creased emphasis on ensuring effective care would encourage increased
technology assessment. The results of such research would be rapidly adopted.

Scenario 3: Access

Under this scenario, policy decisions would be made that attempt to
ensure access to care for all in need, a goal that could be achieved by a
number of mechanisms used singly or together. It could be accomplished

FORCES AND TRENDS IN PERSONNEL DEMAND AND SUPPLY 93

by a scheme of national health insurance that might incorporate mecha—
nisms of cost control. It could also be achieved by expanding public pro—
grams, expanding mandated insurance beneﬁts, ensuring payment to
providers who care for unsponsored patients, requiring all employers to
provide adequate health insurance beneﬁts, and instituting catastrophic
insurance for those with incomplete coverage. Developing an adequate
“safety net” would halt the cost shift to other payers, one way in which
uncompensated care is supported today. This scenario is not necessarily
an alternative to the ﬁrst two scenarios but could occur in tandem with
either.

It is assumed with this scenario that whatever funding arrangements
were made, they would encourage individuals who might have postponed
elective procedures in the absence of third-party payment to seek care in
a timely fashion rather than delay seeking it until they became seriously
ill. Thus, the intensity and complexity of inpatient care would decrease
marginally. It is also assumed that funding would be made available for
health promotion and disease prevention services that are thought to de-
crease total health care costs.

In Chapter 4 we show how these scenarios would affect the demand for
practitioners in each of the 10 allied health ﬁelds named in Chapter 1.

CONCLUSION

This chapter described a number of factors—including aspects of pop-
ulation and economic growth and changes in ﬁnancing and the structure
of the health industry—that drive the demand for personnel in the health
care ﬁelds. It also considered forces that may affect the supply of health
care workers—for example, the growth of the US. labor force and the
college—age population and trends in female students’ choices of study ﬁeld.
Finally, the chapter presented three health care ﬁnancing-driven scenarios
that decision makers may ﬁnd useful in trying to evaluate the future of
speciﬁc allied health professions.

Educators, employers, and others are faced with difﬁcult investment
decisions in planning for future human resource needs. They must make
their best guesses about the forces that drive the demand for and supply
of workers—guesses about their magnitude, the directions they may take,
and their interactions. The answers are not always obvious. There is no
certainty, for example, as to how many AIDS patients will require and
receive physical therapy services or whether sonograms will be routinely
used to screen for cancer. Despite uncertainty, however, it is possible to
learn more about how these forces influence allied health employment and
the supply of workers in allied health ﬁelds. Methods may include tracking
disease and treatment patterns and how allied health practitioners are used,

94 ALLIED HEALTH SERVICES

or identifying new technologies and determining their likely impact on
allied health services. Whatever the methods used, monitoring and inves-
tigating the key forces in the demand for and supply of allied health
personel provides useful insights into the future and better information
for determining policy actions.

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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 US. 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 con-
clusions 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 un-
changed with respect to the rates 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

96

DEMAND AND SUPPLY IN 10 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 inter-
preted 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 esti-
mates 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 sug-
gesting, 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 ex-
ample, 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 employ-
ment. To assist in this process, the committee has indicated how each
profession might be affected by incentives characteristic of the access scen—
arios (which could include new state Medicaid entitlements or a nationally
mandated beneﬁts program) or the prospective payment scenario (which

98 ALLIED HEALTH SERVICES

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 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

 

 

Number of Number of

Employment Setting jobs, 1986 Percentage” jobs, 2000 Percentage“
Total employmentb 239,400 296,300
Total wage and salary

employment 238,400 100.0 295,200 100.0
Hospitals, public and

private 149,800 62.8 160,000 54.2
Ofﬁces of physicians 30,100 12.6 46,200 15.7
Offices of dentists and

other health care

practitioners 890 0.4 1,800 0.6
Medical and dental

laboratories 28,100 11.8 43,200 14.7
Outpatient care facilities 5,300 2.2 13,000 4.4

 

“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.

17Total 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 labo-
ratory 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 US. 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 Profes-
sions, 1985; American Hospital Association, 1987). A survey of the early
impact of the diagnosis-related group (DRG) system on 122 hospital lab—
oratories 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

100 ALLIED HEALTH SERVICES

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 hos-
pital 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 sub-
stantially during the early years of PPS, it rose 19.8 percent in 1985. Possible
reasons for the upturn include increased case complexity, fewer oppor-
tunities to shift care to outpatient settings, and fewer opportunities to
eliminate unnecessary services (Prospective Payment Assessment Commis-
sion, 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 guide-
lines 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 ro-
botics—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 technol-
ogist 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 FIELDS 101

ofﬁce tests are additional tests or substitutes for testing at other sites. An—
other is whether physicians employ clinical laboratory technologists or tech-
nicians. 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 in-
creasing 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 op-
portunities 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 dis-
cussed 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 auto-
mation, 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-

102 ALLIED HEALTH SERVICES

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 em-
ployment 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 technolo-
gists 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:

0 policies concerning AIDS screening;

0 policies concerning substance abuse testing;

0 technological change;

0 payers’ attempts to control test volumes;

0 quality concerns; and

0 trends in state and federal regulation of laboratory settings.

DEMAND AND SUPPLY IN 10 FIELDS 103

The three scenarios described in Chapter 3—mixed ﬁnancing, pro-
spective 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 man-
agement 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, de—
mand 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 tech—
nology has shown a downward trend since the end of the 19705. In 1986
4,477 medical technologists graduated from accredited programs, a de-
crease 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 clo-
sures 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, how-
ever, 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 grad-
uates 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 certifi-
cate 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).

104 ALLIED HEALTH SERVICES

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 tech-
nicians and technologists to be attractive increased substantially (Parks and
Hedrik, 1988). An informal survey by the American Society for Medical
Technology found 54 percent of constituant 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, respec—
tively. Yet this increase is small compared with 18 other types of hospital
employees—of these employees, only engineering technicians had an in-
crease 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. Labo-
ratory 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 micro-
biology. Finally, there are large numbers of uncertifled workers as indicated
by the discrepancy between the BLS job count and the number of certified

DEMAND AND SUPPLY IN 10 FIELDS 105

‘ personnel. These multiple routes of entry into a career in clinical labora-
tories 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 de-
mand 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 pro-
ductivity 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.

106 ALLIED HEALTH SERVICES

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 in-
cluded 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. Con-
tributing 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 occu-
pations). 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 fur-
ther 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

 

 

Number of Number of
Employment Setting jobs, 1986 Percentage" jobs, 2000 Percentage“
Total employment” 86,700 141,000
Total wage and salary
employment 86,700 100.0 141,000 100.0
Ofﬁces of dentists 84,300 97.3 137,300 97.4

 

“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.

bTotal 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 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 em-
ployed 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 ques-
tion remains whether the employment stimulation from increased dental
insurance will be sufficient to offset the effect of such dental disease pre-
vention 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 rela-
tionship between demand for dental care and national economic growth.
The bureau used two different data series for dental expenditures to de-
velop 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

108 ALLIED HEALTH SERVICES

and Dental Health Professions, 1987). Only in the unlikely event that den-
tists become very busy will the momentum of the 19505 to early 19705 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, reach-
ing 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 perio-
dontal 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 phys-
ically 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:

0 number and age of working dentists;

O extent of dental insurance;

0 growth of real personal income;

0 dental disease patterns;

0 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);

0 changes in stafﬁng patterns in solo and group dental ofﬁces; and

O 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 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 Measure-
ments, 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 hy—
gienist 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 an—
ecdotal 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

110 ALLIED HEALTH SERVICES

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 hygien-
ists, 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

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage” jobs, 2000 Percentage“
Total employment” 40,200 53,800
Total wage and salary

employment 38,200 100.0 51,100 100.0
Hospitals, public and

private 14,800 38.7 16,700 32.6
Nursing and personal care

facilities 5,400 14.0 9,000 17.6

 

”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
tables.

"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 [N 10 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 ac-
celerated thereafter (Bureau of Health Professions, 1985; American Hos-
pital 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 num—
ber 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 regu—
lations 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 profes-
sionals such as nurses or ,health educators are thought to provide substi—
tutable 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 phe-
nomenon, 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 in—
stitutional as well as home settings. (Here, too, however, other professionals
such as pharmacists compete with dietitians to provide services.) Further-

112 ALLIED HEALTH SERVICES

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 impor-
tance consumers place on nutritional advice in obesity and cholesterol con-
trol. 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 H MOs, 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 employ—
ment 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 FIELDS 113

The following is a list of factors that are important determinants of
demand for dietitians:

0 consumer desire for nutritional advice;

0 new places of employment such as the food industry and publishing;

0 trends in private practice;

0 trends in the substitution of other professionals (nurses, health edu-
cators, home economists, pharmacists) for dietitians; and

0 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 M ixed 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 ad-
missions 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 infor-
mation from all sources—food labeling, publications, independent prac-
titioners, and the like.

S cenano 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 con-
straint. In addition, access to services for groups with special nutritional

114 ALLIED HEALTH SERVICES

needs, such as migrants and pregnant teenagers, would stimulate the de-
mand 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 de-
grees 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 con-
clusion 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 ad—
dition, 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 per-
sonnel—for example, nonregistered graduates of dietetic programs and
graduates of home economics or food service management programs. It

DEMAND AND SUPPLY IN 10 FIELDS 115

is possible that these latter groups will be used in greater numbers if em-
ployers 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 tech-
nology 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 19705; 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 US. labor
force. BLS notes that this slow growth in employment will be shaped by
conﬂicting forces. On one hand, population growth, especially the pro-
portion 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 termi-
nation 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 govern-
ment, but overall demand should not be much affected by a change in
employer.

There also appears to be movement toward the privatization of emer-
gency medical services. Along with large companies that provide services
on a contractual basis, there has been growth in physician-owned ambulance

116 ALLIED HEALTH SERVICES

TABLE 4-4 Major Places of Wage and Salary Employment for
Emergency Medical Technicians, 1986 Actual and Projected for the
Year 2000

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage“ jobs, 2000 Percentage“
Total employment” 65,200 75,000
Total wage and salary

employment 65,200 100.0 75,000 100.0
Local and interurban

transit 25,500 39.2 27,900 37.2
State and local

governments( 24,500 37.6 29,700 39.6
Hospitals, public and

private 14,600 22.4 16,200 21.7

 

“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.

[’Total employment = wage and salary employment + self—employment.

‘These figures do not include government hospitals and schools.

SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

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.

BLS also predicts that hospital employment of EMTs will increase by 11
percent. This projection is based on a determination that hospitals, ex-
pecting 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 departments—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 availa-
bility 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 par-
amedics is likely to increase sharply relative to other levels of EMTs. Vol—

DEMAND AND SUPPLY IN 10 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 non—
emergency 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 pro-
grams 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—Cali-
fornia, 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-time employed EMTs is said to range between 20 and 40 per-
cent.

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 emer—
gency services has begun to surface in some cities. Should this anxiety

118 ALLIED HEALTH SERVICES

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 pred-
icated 0n 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 de—
mands 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 Amer-
ican Hospital Association show that medical record technician employment
in US. 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 As-
sociation, 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 FIELDS 119

hospital record departments ﬁlled coding positions exclusively with cre-
dentialed 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 de-
mand for medical record technicians are not clear. However, retention of
the paper medical record appears to be common because computer tech-
nology 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

120 ALLIED HEALTH SERVICES

TABLE 4-5 Major Places of Wage and Salary Employment for
Medical Record Technicians, 1986 Actual and Projected for the
Year 2000

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage” jobs, 2000 Percentage“
Total employmentb 39,900 69,800
Total wage and salary

employment 39,900 100.0 69,800 100.0
Hospitals, public and

private 24,500 61.5 40,800 54.2
Nursing and personal care

facilities 4,500 11.2 7,500 10.8
Outpatient care facilities 3,600 9.1 9,000 12.9
Offices of physicians 2,400 6.0 5,800 8.3

 

“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.

bTotal employment = wage and salary employment + self-employment.

SOURCE: Bureau of Labor Statistics (1987); moderate alternative.

percent) overall increase in demand to the year 2000 is supported by the
expansionary forces at work.

For those looking to the future, the following are important factors that
should be monitored:

0 changes in payment systems and regulation;

0 growth of new employment opportunities in out-of—hospital settings;
0 impact of automation; and

0 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 techni-
cians. 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 rel—
atively small: approximately 9,500 people have graduated with the cre-
dential since 1970 (CAHEA, 1979, 1980, 1981, 1982, 1983, 1984, 1985a,

DEMAND AND SUPPLY IN 10 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 ade-
quate for this work. Given this uncertainty, it is not possible to discuss
differences in future demand for medical record administrators and med-
ical 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 administra-
tors, 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 con—
centrate 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 in-
creased 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

122 ALLIED HEALTH SERVICES

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, cur-
rent 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 num-
ber of specially trained workers should grow, enabling employers to con-
tinue 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 institu-
tions and hospitals). BLS classiﬁed 4.5 percent of jobs as being in “ofﬁces
of other practitioners”—that is, ofﬁces of practitioners other than physi-
cians (including osteopaths) and dentists and including the ofﬁces of in-
dependent practice occupational therapists (Table 4—6).

DEMAND AND SUPPLY IN 10 FIELDS 123

TABLE 4-6 Major Places of Wage and Salary Employment for
Occupational Therapists, 1986 Actual and Projected for the Year
2000

 

 

Number of Number of

Employment Setting jobs, 1986 Percentage" Jobs, 2000 Percentage‘l
Total employment” 29,400 44,600
Total wage and salary

employment 26,300 100.0 40,000 100.0
Hospitals, public and

private 9,600 36.3 13,700 34.3
Outpatient care facilities 16,000 6.3 3,400 8.6
Ofﬁces of physicians 400 1.5 760 1.9
Ofﬁces of other health

care practitioners‘ 1,200 4.4 3,100 7.9
Educational institutions,

private and public 4,400 16.7 5,100 12.8
Federal, state, and local

government institutionsd 3,500 13.2 4,100 10.2

 

"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.

hTotal 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.

”Ofﬁces of health practitioners other than physicians (including osteopaths) and dentists.
The figures also include ofﬁces of occupational therapists.

dThese 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 im-
portant 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
US. 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-

124 ALLIED HEALTH SERVICES

pital employment results from more hospitals offering occupational ther-
apy 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 occu-
pational 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 occu-
pational 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 oc—
cupational therapy services are often provided by contractors to, for ex-
ample, 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 FIELDS 125

it seems likely that some of the decrease is due to increased contracting
for services.

In 1986 new federal legislation (Public Law [PL] 99-457) was enacted
that should increase demand for occupational therapists by the educational
sector. This legislation increased federal funds to encourage state depart-
ments 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 edu-
cation (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 neo—
nates. In 1973 no respondent to a survey by the American Occupational
Therapy Association reported head injury as being among the most fre-
quently seen problems. By 1986, 3.3 percent reported head injuries as the
problem seen most frequently. Similarly, developmental disabilities (ex-
cluding 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 ﬁ-
nancing side, efﬁciency incentives and competition are expected to continue
to force facility managers to seek ways to reduce costs. Occupational ther—
apists 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 de—
mand 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 pay-
ment for rehabilitation services. Although the extension of PPS on a di-
agnosis basis in rehabilitation is unlikely, the introduction of some sort of
incentives for economic restraint are slated for implementation.

126 ALLIED HEALTH SERVICES

Factors that should be monitored by those interested in assessing the
demand for occupational therapists include the following:

0 Medicare payment and regulations for rehabilitation services;

0 growth of the hospital sector;

0 demographics concerning school-age children and programs for hand-
icapped children;

0 participation of home care and other long—term care services; and

O 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 M ixed 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 scen-
ario would create downward pressure on the demand for occupational
therapists. Under this scenario, managers in general hospitals would scru—
tinize cost-effectiveness studies for evidence that occupational therapy de-
creases 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 FIELDS 127

apists, providing rehabilitation services for newly entitled groups were in-
corporated into new beneﬁt packages. Orthopedic problems that might
have remained untreated for lack of funding would be cared for; in ad-
dition, 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 19805 the number of ac-
credited 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 Oc-
cupational Therapy Association, Research Information and Evaluation Di—
vision, 1986a).

The committee heard persistent reports of employers’ difﬁculties in re-
cruiting 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 sup-
ply 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

128 ALLIED HEALTH SERVICES

faculty shortages, the committee expects to see health care employers mak-
ing some adjustments that use the existing labor force more effectively and
that encourage extended tenure and return to the labor force. Such ad-
justments 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 im-
provements 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 pre-
dicted growth rate for physical therapists is due to the BLS analysts’ de—

DEMAND AND SUPPLY IN 10 FIELDS 129

TABLE 4-7 Major Places of Wage and Salary Employment for
Physical Therapists, 1986 Actual and Projected for the Year 2000

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage“ jobs, 2000 Percentage‘l
Total employment” 61,200 114,700
Total wage and salary

employment 56,200 100.0 105,400 100.0
Hospitals, public and private 19,900 35.5 28,400 26.9
Ofﬁces of physicians 3,300 5.8 4,900 4.6
Ofﬁces of other health care

practitionersC 11,500 20.4 36,600 34.7
Outpatient care facilities 3,000 5.3 6,500 6.2

 

“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.

bTotal 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.

‘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.

termination that the same factors drive demand for the two groups. Payers
can have a signiﬁcant effect, however, on the use of assistant-level practi-
tioners. Comments made during the committee’s site visits to hospital phys-
ical 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 require-
ments were felt to limit the usefulness of assistants, resulting in their cur-
tailed employment. Physical therapists themselves have often been reluctant
to use assistants.

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 Profes-
sions, 1985; American Hospital Association, 1987). Other evidence sup—
ports 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-

130 ALLIED HEALTH SERVICES

tained by the expansion of hospital rehabilitation facilities and by the in-
creasing 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 ther-
apists 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 lo-
cation 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 rep-
resenting 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 in-
dependent 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 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 Ther-
apy 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 institution-
alization 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. In-
creased 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

O 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 ther-
apists is reﬂected in the response of such demand to the three scenarios

132 ALLIED HEALTH SERVICES

described in Chapter 3. A downturn in demand is not foreseen in any
scenario.

Scenario 1 : The M ixed 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 de-
mand 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-effec—
tiveness the rate of growth in demand for therapy services would be re-
duced 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 im-
petus if access to care were increased. Under this scenario, nonacute prob-
lems 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 pa-
tients would relieve some of the ﬁnancial pressures on hospitals, which in
turn would allow a lessening of productivity pressures and greater re-
sponsiveness to patients’ demand for physical therapists.

DEMAND AND SUPPLY IN 10 FIELDS 133

Supply of Physical Therapists

Graduations from accredited baccalaureate, master’s degree, and certif—
icate 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, per-
sonal 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 stu-
dents 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 ther-
apists 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

134 ALLIED HEALTH SERVICES

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—prob-
ably 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 edu—
cational capacity can accommodate, salary increases will not be the most
effective way of bringing new people 1nto 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 ad—
justing 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 1s a matter of contention. Some say that

DEMAND AND SUPPLY IN 10 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 (Hav-
inghurst, 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 expen-
ditures (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 reso-
nance 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 increas-
ing employment opportunities in nonhospital settings such as HMOs, im-
aging 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—fr0m 70,200 in 1986 to

136 ALLIED HEALTH SERVICES

TABLE 4-8 Major Places of Wage and Salary Employment for
Radiologic Technologists and Technicians, 1986 Actual and Projected
for the Year 2000

 

 

Number of Number of

Employment Setting jobs, 1986 Percentage“ Jobs, 2000 Percentage“
Total employment” 115,400 190,100
Total wage and salary

employment 114,400 100.0 188,200 100.0
Hospitals, public and private 70,200 61.4 91,600 48.7
Outpatient care facilities 2,500 2.2 9,400 5.0
Ofﬁces of physicians , 31,300 27.4 71,000 37.7
Ofﬁces of dentists 1,200 1.0 1,900 1.0
Ofﬁces of other health care

practitioners 1,500 1.3 4,000 2.1

 

“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.

bTotal 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.

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 4-9 Major Places of Wage and Salary Employment for
Nuclear Medicine Technologists, 1986 Actual and Projected for the
Year 2000

 

 

Number of Number of

Employment Setting jobs, 1986 Percentage“ jobs, 2000 Percentage"
Total employment” 9,700 1 1,900
Total wage and salary

employment 9,700 100.0 11,900 100.0
Hospitals, public and private 8,600 88.6 10,000 839
Medical and dental labs 500 5.2 700 6.1
Ofﬁces of physicians 400 4.1 800 6.6

 

“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.

[’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 FIELDS 137

Pre- and post-PPS employment patterns in hospitals appear to offer equiv-
ocal support for this notion.

According to American Hospital Association data, x-ray technologist,
radiation therapy technologist, and nuclear medicine technologist employ-
ment declined between 1983—1985, compared with 1981—1983, when em-
ployment 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 As-
sociation, 1987). It is difﬁcult to ascertain exactly what changes are occur-
ring. In a 1985 survey of nuclear medicine department directors,
administrators, or chief technologists, 20 percent of the respondents re-
ported a decline in the number of employed nuclear medicine technologists,
65 percent reported a decrease in inpatient volume, and 58 percent re-
ported an increase in outpatient volume. These data were interpreted as
the product of lowered admissions, of physicians ordering fewer tests, and
0f 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 pro-
cedures 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 ul-
trasound, various computerized tomography (CT) studies, and radiother-
apy 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

138 ALLIED HEALTH SERVICES

to the 19705, the new application of computer technology to imaging has
generated major improvements in diagnostic capabilities. The new tech-
nologies 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 pro-
cedures 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 im—
aging 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 capabili—
ties, 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 oc-
cupations. 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 FIELDS 139

0 hospital utilization, especially intensity of care and case mix;

0 growth of all types of freestanding facilities;

0 licensure changes;

0 technological changes that are likely to cause new areas of
specialization; and

0 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 M ixed 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 tech-
nologists in hospitals would slow as admissions fell even though the intensity
ofcare increased for an older, sicker patient population. The use of imaging
as an aid to speedy diagnosis and discharge would be encOuraged. Radio-
logic 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 ra—
diology 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.

140 ALLIED HEALTH SERVICES

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 pro-
spective payment.

Two smaller and newer radiologic specialities—nuclear medical tech-
nology 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 ed-
ucation 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 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 op-
erators and engineering technicians—occupations that may be competing
for the same students (University of Texas Medical Branch, 1986). Edu-
cation 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 them-
selves 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 respi-
ratory 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 occu-
pations (e.g., clinical laboratory technologists or nuclear medicine tech-
nologists). 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 tech-
nician 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. Al-
though BLS predicts only a 12.2 percent increase in overall hospital em—
ployment through the year 2000, its analysts expect hospital demand for
respiratory therapists to increase by 25 percent because of the increased

142 ALLIED HEALTH SERVICES

admissions of older, sicker patients who require more intensive care. BLS
also sees some demand for respiratory therapy being generated by im—
provements 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 partic-
ular 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 respi-
ratory 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

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage" jobs, 2000 Percentage“
Total employment” 56,300 75,600
Total wage and salary

employment 56,300 100.0 75,000 100.0
Hospitals, public and private 49,400 87.7 61,900 81.8
Outpatient care facilities 700 1.2 1,500 2.0
Ofﬁces of physicians 500 0.9 1,100 1.5
Ofﬁces of other health care

practitioners" 2,000 3.5 3,300 4.3
Other health and allied health

care facilities” 3,400 6.1 7,300 9.7

 

“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.

bTotal employment = wage and salary employment + self—employment. Self—employed
persons are not allocated by place of employment.

‘Ofﬁces of health practitioners other than physicians (including osteopaths) and dentists.

dHealth 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 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 respi-
ratory therapist either as a staff member or as a contracted consultant
(Health Care Financing Administration, 1986b). A recent report to Con-
gress 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 Med-
icare under the durable medical equipment beneﬁt. Equipment supply
companies support home patients by hiring professional staff (e.g., respi-
ratory therapists) who can supervise the installation of equipment and
undertake patient education. (However, the American Association of Re-
spiratory Care reportedly has had difﬁculty in tracking employment in
durable medical equipment companies.) Despite perceptions that increas-
ing 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 asso-
ciation 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 respi-
ratory-related diagnoses stayed the same or increased in 70 percent of the
hospitals. However, in respiratory therapy departments the personnel bud-
gets and level of employment were generally either stable or decreased
(American Association for Respiratory Care, 1986b) suggesting that im-
provements in productivity had occurred.

Other changes that are occurring within hospitals can generate continued
steady employment growth for respiratory therapists. As suggested by BLS,

144 ALLIED HEALTH SERVICES

respiratory therapists are increasingly being used to provide non-respira-
tory 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 cath—
eterization 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 pul-
monary disease and lung cancer exemplify diseases to which elderly people
are particularly prone.

Countering these upward movements in demand are downward pres-
sures 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 em-
ployment 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 em-
ployment 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 FIELDS 145

o the expansion of activities of respiratory therapists into new areas;
0 Medicare reimbursement of respiratory therapists in home care;
0 employment by the durable medical equipment industry; and

O 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 con-
tinue 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 1 .' The M ixed 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 uti-
lization 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 em-
ployment in the hospital sector would overwhelm all other effects.

S cenano 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.

146 ALLIED HEALTH SERVICES

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 signif-
icant 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 cul-
minate in certiﬁcation or licensure or both. As a result the shorter programs
that provide training for the lower level respiratory technicians are dis-
appearing. 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 educa-
tional 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 de-
mand there is excess educational capacity. Furthermore, the trend in grad-
uates 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 re—
spiratory 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 ther-
apists 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 main-
tained at approximately today’s level, the nation’s supply of respiratory

DEMAND AND SUPPLY IN 10 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 attractive-
ness 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 per—
cent) of the respiratory therapy labor force. The signiﬁcance of this rep—
resentation 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 mas-
ter’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

148 ALLIED HEALTH SERVICES

outside the health care system. In 1986 only 28.6 percent of speech—lan-
guage 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 pa-
thologists 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

 

 

Number of Number of

Employment Setting Jobs, 1986 Percentage“ jobs, 2000 Percentage“
Total employment” 45,100 60,600
Total wage and salary

employment 42,100 100.0 56,500 100.0
Educational institutions, public

and private 27,000 64.0 30,800 54.62
Hospitals, public and private 4,400 10.4 5,600 9.9
Outpatient care facilities 2,700 6.4 4,400 7.7
Nursing and personal care

facilities 1,200 2.7 1,900 3.4
Ofﬁces of physicians 1,800 3.6 2,900 5.2
Ofﬁces of other health care

practitioners” 1,200 2.7 4,400 7.7

 

“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.

[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.

‘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 FIELDS 149

There is considerable support for the BLS estimates. Although speech—
language pathologists and audiolbgists may see new opportunities for em-
ployment 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 posi-
tioned 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 reimburse-
ment system that includes cost-control incentives. Medicare will also reim—
burse 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 Associa-
tion, 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 free-
standing home health agencies offer speech—language and audiology ser-
vices (American Speech—Language—Hearing Association, Task Force on
Home Care, 1986).

Although only a minority of speech—language pathologists and audiol-
ogists are employed in hospitals, their use in that setting has not been
constrained by PPS. Indeed, between 1983 and 1985 their FTE employ-
ment in hospitals increased by 21 percent from 2,684 to 3,252. Committee
site visits uncovered several possible reasons for this increase. One is ex-
panded 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

150 ALLIED HEALTH SERVICES

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 grow-
ing numbers of elderly patients using their services plus an increasing
understanding of their work by physicians that has resulted in more nu-
merous 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:

0 Medicare reimbursement of rehabilitation services;

0 school system growth and ﬁnancing;

0 patterns of speciﬁc diseases and treatment such as stroke, head trauma,
and deafness in youth; and

0 growth in independent practice opportunities and contractual ar-
rangements 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 M ﬁxed 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 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 low-
ered and previously ignored communicative deﬁcits would receive atten-
tion, 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 de-
grees. The total number of programs has been quite stable since 1983,
ranging between 293 and 304 (Cooper et al., 1987). The number of bach-
elor’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 disci-
plines. 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 de-
gree 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

152 ALLIED HEALTH SERVICES

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 im-
provements in the conditions of employmentshould not be expected. How—
ever, 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 per-
sonnel demand and supply.

For some ﬁelds (e.g., physical therapy, radiologic technology, medical
record technology and administration, and occupational therapy), we fore-
see 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 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 in-
action 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, audiol-
ogists, 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 equi-
librium 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 adjust-
ment 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 de-
cision to intervene in the labor market is made through the political process
and reﬂects society’s willingness—or unwillingness—to tolerate painful dis-
locations. 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.

154 ALLIED HEALTH SERVICES

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5

The Role of Educational Policy in
Inﬂuencing Supply

 

IF NO STEPS ARE TAKEN to bolster the future supply of personnel in
several allied health ﬁelds, health care institutions will be hampered in
meeting the public’s demand for services. These steps will require coor-
dinated actions by educators and employers, encouraged by modest but
strategic federal, state, and private programs. Many of the recommenda-
tions in this and the following chapter are directed toward educators, em-
ployers, and the allied health professions themselves. Although the committee
believes its recommendations will be beneficial to those parties, it looks to
public intervention to stimulate and amplify their implementation.

This chapter is divided into three sections. The ﬁrst deals with policies
to inﬂuence the decisions of persons choosing careers. The second discusses
the role of educational institutions in maintaining or expanding enroll-
ments. The third addresses concerns about the preparedness of the future
allied health work force.

THE ALLIED HEALTH STUDENT APPLICANT POOL

For most ﬁelds the available trend data on allied health programs and
graduations do not signal an imminent crisis requiring dramatic public
intervention. Looking to the future, however, the committee is deeply
concerned that the weak infrastructure of allied health education may
compromise the system’s ability to maintain enrollments, let alone increase
the supply of personnel in fields in which employment demand is high. A
key to the viability of allied health education is its capacity to maintain its

159

150 ALLIED HEALTH SERVICES

share of qualiﬁed students from the traditional college-age applicant pool
while tapping into less traditional pools of students, particularly minority
students.

For a number of years, allied health deans and program directors have
expressed concern about the declining number of applicants to their pro-
grams and the implications of this decline for the academic quality of the
student body. Reportedly, spaces in many programs are going unﬁlled,
and this lack of student interest is jeopardizing the survival of academic
programs. Comprehensive data collection concerning applicants to allied
health programs is not currently being done. However, CAHEA annually
surveys program directors in several allied health fields about whether
applications to their programs are increasing, decreasing, or remaining
stable. In its 1987 survey, program directors in 13 of 22 fields reported
decreases in the number of applicants (CAHEA, 1988).

The clinical laboratory ﬁelds in particular were experiencing distress.
For example, almost two-thirds of the medical technology program direc-
tors reported decreases in applicants in 1987. Of the 116 programs that
voluntarily withdrew from CAHEA accreditation between 1983 and 1987,
36 attributed their decisions to a declining applicant pool.

Unpublished survey data from the American Society of Allied Health
Professions suggest that only physical therapy has a large applicant pool
to draw upon, with about five applicants per academic space. Other fields
such as dietetics, medical technology, radiologic technology, and medical
record administration average. only slightly more applicants than needed
to ﬁll their classes.

A recent (1987) survey of the College of Health Deans, an organization
composed of allied health administrative units in 20 universities without
medical centers from 17 states, revealed that only 3 out of 17 respondents
reported that all of their professional classes were filled. Although clinical
laboratory programs were those most frequently cited as having excess
capacity, many other fields also reported unfilled classes.

Although the current level of applications worries academic administra-
tors, they are even more concerned about the future because of the pre-
dicted decline in the college-age cohort of the population, an issue discussed
in Chapter 3. This decrease suggests that in the future there may be even
greater competition among schools for technically oriented students than
there is today. Information from annual surveys of college freshmen on
changing occupational preferences shows a slow but steady decline (from
3.3 percent to 1.1 percent) between 1977 and 1985 in women’s interest in
careers in laboratory technology and dental hygiene, dietetics and home
economy (from 1.1 percent to 0.4 percent), and health technology (from
3.7 percent to 1.8 percent). Women’s interest in the category headed “ther-
apist” has remained relatively stable over the period; men have exhibited

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 161

gradually increasing interest over the years (Cooperative Institutional Re-
search Program, 1987).

Academic administrators are also concerned that, with fewer applicants
from which to select, the quality of students will decline. Thus far, except
for the areas of clinical laboratory sciences and radiography, no decrease
in student quality seems to be evident to program directors, as measured
by the CAHEA survey. More objective evidence for assessing quality changes,
such as grade point averages or test scores during students’ ﬁrst year of
professional course work, is not routinely collected. The American College
Testing (ACT) Program test scores of high school juniors who intend to
major in allied health ﬁelds do not bear out a shift in quality (Table 5-1),
although the downward trend in dental hygiene may deserve some atten-
tion.

Not every allied health ﬁeld has experienced an applicant deﬁcit, as
evidenced by what has occurred in the physical therapy ﬁeld. Despite a
rapid increase in the establishment of physical therapy programs, most
directors report that they still have more than an adequate supply of ap—
plicants and can limit enrollment to those with high grade point averages.
It is not unusual to ﬁnd physical therapy programs with application—to-
acceptance ratios of 10 to 1. In addition to physical therapy, a few Of the
newer professions such as perfusion and diagnostic medical sonography
are also in great demand, with about 60 percent of program directors
experiencing application increases (CAHEA, 1988).

Because they are fewer in number and smaller in size, it is difﬁcult to
equate the success of programs like perfusion, for example, with programs
in physical therapy. Nonetheless, characteristics of perfusion programs are
worth noting. Some of the students are often drawn from other disciplines

TABLE 5-1 ACT Test Score Means for Students Specifying Academic
Majors

 

Percentage of

 

 

ACT Composite Test Scores Change,

Academic Major 1980-1981 1983—1984 1985—1986 1986—1987 1980—1987
Dental assisting 13.3 13.2 13.5 13.3 0
Dental hygiene 16.1 15.5 15.4 15.0 — 1.1
Medical technology 18.2 18.2 18.6 18.2 0
Occupational therapy 16.7 16.6 17.5 17.5 — 0.8
Physical therapy 17.8 18.0 18.8 18.5 1.0
Radiological technology 14.4 15.4 15.9 15.8 1.4
Nursing (RN) 162 15.9 16.3 15.9 — 0.3
Pharmacy 20.0 19.8 20.4 20.1 0.1
Overall college-bound

population 18.5 18.2 18.3 18.7 1.1

 

SOURCE: Unpublished data from the American College Testing Program.

152 ALLIED HEALTH SERVICES

(respiratory therapy and critical care nursing, for example) and therefore
have had some exposure to the new ﬁeld. Employment opportunities abound,
and not all graduating students enter the clinical ﬁeld because other at-
tractive opportunities are often available. For example, manufacturers and
biomedical engineering laboratories hire some perfusionists; some enter
medical school and others choose teaching. Although perfusion is a high-
stress profession, it is also a relatively well-paid one. The average salary for
a graduating student is $35,000, but highly qualiﬁed and experienced
perfusionists may earn close to $100,000. Although they are not known to
the general public, perfusionists are respected in the allied health world
for their success in garnering earnings and their relative independence
(Brown, 1987).

Why do some programs fare better than others in attracting students?
Some reasons come readily to mind. Undoubtedly, the positive economic
outlook for physical therapy—rising salaries, growing autonomy, and high
levels of demand for graduates—has affected student thinking. Also, in
comparison with such ﬁelds as clinical laboratory technology, physical ther-
apy has greater public visibility and more patient contact.

There may be lessons to be learned from schools of social work, which
have succeeded in increasing their applicant pool from 2 applicants per
opening in 1983 to 3.5 applicants per opening today. Social work is con-
sidered to be closely related to (if not directly under the umbrella of) allied
health. Deans of schools of social work attribute the revitalization of interest
in social work careers to a wide variety of social and economic factors,
including the following:

0 optimism about the status of social welfare programs in the post—
Reagan era;

0 a surge (although not as dramatic as during the 1960s) in the sense
of social commitment among students;

0 occupational outlook projections of higher-than-average growth in de-
mand;

0 growth of independent practices and third-party payment;

0 adoption by some schools of “business-like” approaches to marketing
and recruiting students; and

0 salaries that, while not high initially, averaged about $27,800 in 1986—
1987 (Health Professions Report, 1988).

Visibility and comparatively high pay are elements that contribute to the
attractiveness of a ﬁeld, and these in turn contribute to the success of schools
in obtaining high application rates. Some ﬁelds that are viewed by the allied
health community as being attractive and offering well-paying careers none-
theless do poorly in attracting students because they lack visibility. For
example, occupational therapy shares many of the attributes of physical

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 163

therapy, but its role in health care is not well known. Medical record
administrators can earn over $50,000 per year and advance to hospital
executive positions, but that field, too, is little known to the public.

Some allied health occupations (e.g., medical technology and radiogra-
phy) do not offer particularly good economic rewards but seek to attract
scientifically oriented students to work in potentially hazardous environ—
ments in which they may be exposed to contaminated body ﬂuids or ra-
diation. Moreover, although laboratory and radiography employment
prospects may be rebounding after PPS cutbacks, the atmosphere of job
insecurity may still be inﬂuencing students’ perceptions about those ﬁelds.

Student Recruitment

Many of the social factors that inﬂuence career choice are beyond the
control of health care institutions or academics. The economic attractiveness
of careers and their work environments are largely in the hands of em-
ployers (a topic that is addressed in Chapter 6) and those who make reim-
bursement decisions.

There are a number of techniques that schools have used to attract
students. Among them are the use of professional recruiters, giving faculty
release time to visit high school counselors and students, the distribution
of videotapes about the school, and undertaking national promotions (e.g.,
Lab Week, fostered by the American Society for Medical Technology).
Unfortunately, such efforts to inﬂuence students’ career choices toward an
allied health field have not been systematically documented or evaluated.

Many psychological and social theories of career choice and career de-
velopment have emerged over the years to explain how individual career
development unfolds over the life span. These theories suggest the difﬁ-
culties of intervening in a complex process. Career development is shaped
by an interplay of psychological attributes, knowledge about training re-
quirements, educational and occupational opportunities, genetic and child-
hood inﬂuences, evolving personalities, and patterns of traits that individuals
express cognitively and psychologically in their choice behavior. Research
related to career development ﬁnds that, like all human behavior, it is a
highly complex process and is part of the total fabric of personality (Lent
et al., 1986).

Most of the existing approaches to career development are based on
limited samples of relatively privileged persons. The samples typically have
been composed of men rather than of women, and the approaches to
career development in general have been addressed to persons in the
middle range of socioeconomic characteristics. Consequently, these ap-
proaches tend to emphasize the continuous and progressive aspects of
career development that are possible primarily for persons who are rela-

164 ALLIED HEALTH SERVICES

tively free to choose any career and for whom both psychological and
economic resources are available. Such criteria do not necessarily ﬁt women
and minorities (Fitzgerald and Crites, 1980).

The impact of several variables (including parental socioeconomic status
[SES], academic achievement, and sex) on both selection and persistence
in career choice has been investigated in an attempt to determine who is
being recruited into professions in general. These variables were used to
analyze responses from the US. Department of Education’s 1972 National
Longitudinal Study and recent follow-up surveys. Results showed that chil-
dren of high-SE8 parents were four times more likely than children of
low-SES parents to engage in professional study at the baccalaureate level
and six times more likely to participate in or complete professional training
at the graduate level. The SES level of parents did not have as much effect
on the aspirations of children, however; children of high-SES families were
only twice as likely to wish for a professional career as their contemporaries
from low-SES families. Researchers have concluded that the idea of sub-
stantial social and economic mobility in the United States has been exag-
gerated and is difﬁcult to achieve. Only 2 percent of young people from
low-SES homes were in graduate-level professional programs 7 years after
high school, despite large federal student aid programs and numerous
corporate and foundation programs to stimulate opportunities in the
professions (Miller, 1986).

In general, the career choice literature does not provide detailed guid—
ance for recruitment efforts. Yet several implications for speciﬁc planning
interventions can be seen.

0 The concepts that people are only economic animals and that work is
chosen only for the livelihood it offers are too simplistic. Work also provides
a means for meeting the needs of social interaction, dignity, self-esteem,
self-identiﬁcation, and other forms of psychological gratiﬁcation.

0 Personal, educational, occupational, or career maturation comprises
complex learning processes that begin in early childhood and continue
throughout life.

0 Choice occurs not at a point in time but in relation to antecedent
experiences and future alternatives.

0 Career information must include not only objective factors such as
earning possibilities, training requirements, and numbers of positions avail-
able but the social and psychological aspects of careers as well.

0 Career choice is frequently a compromise between the attractiveness
of an alternative, the likelihood of attaining it, and the costs of attaining it
(Herr and Cramer, 1984).

In sum, the literature on career choice is suggestive rather than pre-
scriptive for recruitment tactics. Long-range efforts must take into account

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 165

the need to make individuals aware of careers at an early stage. If women
continue to predominate in many of the allied health ﬁelds, we must learn
more about the dynamics of their career choice behavior.

Successful student recruitment efforts generally depend on positive mar—
ket signals emanating from the world of work. In the next chapter the
committee discusses actions that emplOyers must take to improve the cir-
cumstances of allied health personnel in work settings in which the per-
ceptions of unsatisfactory careers accurately reﬂect reality. However, to the
extent that potential students incorrectly believe that a career is unsatis—
factory, the problem may require improved communication. Local con-
sortia of professional association members, employer representatives, and
educators should be formed to devise recruitment strategies based on com-
munity needs, characteristics, and resources. These consortia should target
nontraditional audiences, tailoring the message and method of commu-
nication to each. A marketing plan geared to attracting newly unemployed
workers from a local industry, for example, should not be the same as one
that seeks to attract displaced homemakers or handicapped high school
students.

The demand for technically oriented people is growing in many sectors
of the economy. One study predicts that

The jobs that will be created between 1987 and 2000 will be substantially different
from those in existence today. A number of jobs in the least-skilled job classes will
disappear, while high-skilled professions will grow rapidly. Overall the skill mix of
the economy will be moving rapidly upscale, with most new jobs demanding more
education and higher levels of language, math and reasoning skills. (Hudson In-
stitute, 1987)

More speciﬁcally, more than half of the new jobs created between 1984
and the year 2000 will need some high school education. Nearly a third
will require a college degree; today, only 22 percent of occupations require
a college degree (Hudson Institute, 1987). The health care industry is not
the only industry that is beginning to understand that one of the challenges
of the future will be to position themselves favorably in the competition
for the supply of educated, technically able workers. For some allied health
ﬁelds, there are already indications that potential practitioners are being
lost to other professions. It is clear that educators, employers, and the
professional associations must act if they want to maintain or increase their
share of the work force. The process of change is necessarily interactive.
If employers succeed in making allied health employment more attractive,
educational institutions will experience increases in the size and quality of
the applicant pool. Yet, circularly, the extent to which employers are able
to alter the conditions of employment depends in part on the education
that workers have received.

166 ALLIED HEALTH SERVICES

The committee recommends that educational institutions, in close col-
laboration with employers and professional associations, organize for the
recruitment of students. They should seek persons from less traditional
applicant pools—minorities, older students, career changers, those al-
ready employed in health care, men (for fields in which they are under-
represented), and individuals with handicapping conditions.

Minorities

Two major societal problems underlie concerns about minority partici-
pation in allied health careers, leading the committee to devote special
attention to this issue.

First, as several recent public policy documents have stated, minority
populations in the United States have comparatively poor health statuses
and use fewer health care resources relative to their needs (US. Department
of Health and Human Services, 1985). Although a causal relationship be—
tween the supply of minority practitioners and improved minority health
care and health status is difﬁcult to validate, minority health care workers
are more likely to work in geographic areas and at delivery sites that serve
minority and other disadvantaged patients. Ofﬁcials interviewed at three
inner-city hospitals, including two public hospitals, said that minorities are
at least 50 percent of their total allied health work force. Moreover, data
extracted from facility records show that this pattern is relatively uniform
across such different ﬁelds as clinical laboratory technology, physical and
occupational therapy, dietetics, and medical records (Booker, 1987).

Second, there is a lack of parity throughout American society between
whites and nonwhites in professional positions. To the extent that the allied
health fields can provide improved career opportunities for minorities, a
double beneﬁt will occur: education programs will be better able to maintain
enrollments, and personnel shortages may be alleviated in underserved
geographic areas and institutions that serve poor minority populations.

To supplement a review of the literature on the representation of mi-
norities in allied health ﬁelds, the committee conducted extensive interviews
with deans and faculty of 10 schools active in the National Society for Allied
Health (an organization committed to increasing the participation of black
and other disadvantaged minorities in allied health practice, education, and
administration). Other schools were added in an attempt to broaden the
information base. A school known to have a predominantly Hispanic stu-
dent body and structured activities to recruit Hispanics to allied health
programs was selected, as was a school in an area with a large American
Indian population. Finally, a nonminority school in the South was added
because it boasts the largest number of allied health programs on a single
campus and has been actively involved in minority allied health recruitment

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 167

and retention efforts for some time (Booker, 1987). Pertinent information
from these interviews will be referred to in our discussion of minorities in
allied health education.

Table 5-2 presents estimates of racial and ethnic characteristics of allied
health personnel based on the results of an analysis of the 1980 census.
The data show that minority personnel are underrepresented, relative to
their representation in the US. labor force, in the 10 allied health ﬁelds
studied by the committee and particularly in the ﬁelds requiring higher
education.

CAHEA reports that over the entire range of the ﬁelds it accredits the
racial mix of students enrolled during 1986—1987 generally mirrored the
racial mix of the US. population. Blacks represented 11 percent of total
enrollments, Hispanics, 6 percent, and American Indians, about 2 percent.
What these data fail to reveal is that minorities are overrepresented in ﬁelds
requiring less education and underrepresented in ﬁelds requiring more
education. The extent to which minorities have a higher departure rate
from programs and careers is not known. Several professional associations
in ﬁelds requiring baccalaureate and advanced degrees have commented
on the need for greater efforts to increase the number of minority students.
For example, the 1984 Study Commission of the American Dietetics As-
sociation noted:

While no effort has been made in the past to restrict other racial groups, or males,
from the profession, little has been done to make the profession more attractive
to them, nor has any strong effort been made to recruit them. The 1984 Study
Commission believes such an effort is overdue.

TABLE 5-2 Distribution of Personnel (Percentage) in Selected Allied
Health Occupations by Race or Ethnic Origin, 1980

 

 

 

Minority
White (not of White Other
Occupation Spanish origin) Black (Spanish origin) Minority"
Laboratory technician 79.5 1 1.1 3.3 6.2
Dental hygienist 95.4 1.6 1.6 1.3
Dietitian 84.6 6.7 1.9 8.0
Medical record technician 84.4 9.5 2.2 3.9
Occupational therapist 94.7 2.1 0.9 2.4
Physical therapist 93.4 3.3 1.1 2.0
Radiologic technician 86.2 7.7 3.7 2.4
Respiratory therapist 82.1 10.0 4.9 3.]
Speech and hearing therapist 92.9 4.3 1.5 1.3

 

“These ﬁgures include American Indians, japanese, Chinese, and other Asians or Paciﬁc
Islanders.

SOURCE: Health Resources and Services Administration (1984).

168 ALLIED HEALTH SERVICES

Past Efforts to Increase Minority Participation

The Federal Government

The federal government ﬁrst initiated programs to encourage “culturally
or economically disadvantaged individuals” to enter allied health as part
of the 1970 health manpower legislation (PL. 91-519). This statute was
extended in 1973 by the Comprehensive Health Manpower Act (PL. 92-
157) and the Health Programs Extension Act (P.L. 93-45) and in 1976 by
the Health Professions Educational Assistance Act (P.L. 94-484). Later, an
administrative decision was made to provide support for projects that em-
phasized the recruitment and retention of minorities as well as the disad-
vantaged (Carpenter, 1982).

Between ﬁscal years 1972 and 1977 approximately $20 million of a total
of nearly $191 million of grants awarded for allied health were allocated
for programs targeting minority and disadvantaged populations. Between
1978 and 1981, under PL 94-484, a larger share of the total but a smaller
amount was awarded for project activities to assist disadvantaged allied
health students (Carpenter, 1982).

By ﬁscal year 1982 the only federal funding of any magnitude that was
available for minority recruitment and retention in allied health training
was the Health Careers Opportunity Program (HCOP). HCOP has ﬁve
objectives: (1) recruitment, (2) preliminary education (noncredit), (3) fa-
cilitation of entry, (4) retention, and (5) information dissemination. Ex-
amples of HCOP activities include career fairs; faculty counseling; tutoring;
summer enrichment programs to enhance mathematics, science, and com-
munication skills; and linkage arrangements among undergraduate schools
such as historically black colleges and universities (HBCUs), community
colleges, and high schools.

Between ﬁscal years 1982 and 1987 the number of allied health grants
under HCOP increased steadily, as did the funds that were awarded. Of
the $60 million or more awarded since ﬁscal year 1985, $5.37 million has
gone to allied health programs. The proportion awarded each year to allied
health programs rose from 5 percent to nearly 10 percent during this 3-
year period (W. Holland, Division of Disadvantaged Assistance, Health
Resources and Services Administration, personal communication, 1987).

The Area Health Education Centers (AHEC) Program assists health
professions schools in improving the distribution, supply, quality, utiliza-
tion, and efﬁciency of health care personnel in the health care service
delivery system by encouraging the regionalization of professional edu—
cation. The program has no legislative mandate to recruit and retain mi-
norities, but it has explicitly encouraged such activities. In ﬁscal year 1987,
AHECs in Arizona, New Mexico, Texas, California, Oklahoma, and at three
black medical schools—Drew (Los Angeles), Meharry (Nashville), and

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 169

Morehouse (Atlanta)—were cited by AHEC ofﬁcials as having active com-
mitments to training professionals to serve Hispanic, Indian, and black
populations. The AHEC ﬁnancial investment in the recruitment and re-
tention of minority allied health students and workers was not obtainable
from available program data (Area Health Education Centers Program,
1987).

States

The health professions education programmatic resources of most states
have been devoted to increasing the supply of minority physicians and
dentists, but a few states support initiatives for minorities in allied health
training. For example, Connecticut funds the Health Sciences Cluster Pro-
gram, which exposes high school students to allied health professions;
economically disadvantaged students in allied health in Georgia are eligible
for a small grant program, the Regents Opportunity Grant Program (Man—
dex, Inc., 1987). New York State has developed an action plan to improve
minority access to the licensed professions (including dental hygiene, speech—
language pathology and audiology, physical therapy, and occupational
therapy), the core of which is a comprehensive effort to improve curriculum
development and teaching in mathematics and science in grades 7 through
12. In addition, the state offers ﬁnancial assistance to allied health students
willing to work in state agencies after graduation (New York State Education
Department, Bureau of Higher and Professional Education Testing, 1985).

Allied health is rarely speciﬁcally identiﬁed in state legislation for targeted
funding. Several investigators report being unable to ascertain the amount
spent for allied health education because these funds are not distinguished
from appropriations for “medical education.” Of the 13 allied health pro-
gram ofﬁcials interviewed (Mandex, 1987), only one reported that the
program received funds for minority recruitment and retention through
a line item in the state budget.

Private Foundations

Private organizations also see merit in encouraging minorities to select
health care careers. The Josiah Macy, Jr., and Robert Wood Johnson foun—
dations have been quite active in these efforts. However, Robert Wood
Johnson Foundation staff report that current activities do not include allied
health professions. Macy has sponsored some allied health professions
training, but its primary focus, after more than 20 years of involvement
in minority health professions education, is still physicians. The Macy ex—
perience is worth describing in some detail because of its potential appli-
cability to allied health education. (The following description is taken from
Bleich [1986, 1987].)

170 ALLIED HEALTH SERVICES

The basic concept of Macy’s high school model is to use foundation
funds to supplement tax levy support for participating schools. Strength—
ening curriculum and premedical advising early in a high school student’s
education is the centerpiece of this program. Linkages between colleges
and universities and the high schools are common and serve as vehicles
for faculty development, student exposure to careers, and academic en-
hancement.

For example, ﬁve high schools located in the three poorest (50 percent
of all families live below the federal poverty level) counties in rural Alabama
have completed a 4—year cycle in the Macy project. Macy reported the
following results.

0 Of the originally selected 114 students, 79 percent were retained in
the honors program.

0 All of the honors students scheduled to graduate did so and are going
to college; all but two anticipate attending a 4-year school.

0 Thirty—three 0f the 88 graduates specified that they would pursue a
health career; 3 speciﬁcally cited physical therapy.

0 The Macy graduates took the mathematics placement exam given to
all University of Alabama incoming freshmen. Of the group, 88 percent
placed into calculus 0r precalculus—55 percent in calculus and 33 percent
in precalculus. Macy notes that less than 10 percent of all Alabama freshmen
did as well (Bleich, 1986).

The program in these schools, which is called the Biomedical Sciences
Preparation (BioPrep) Program and operates in grades 9 through 12, is
conducted in conjunction with the University of Alabama School of Com-
munity and Allied Health, a school committed to increasing the number
of health professionals practicing in rural Alabama. Many of the Macy
graduates (57 of 88) were awarded tuition scholarships by the university.

Prior to the BioPrep program, school systems in the three counties (two
of them predominantly black with a median of 8.5 completed school years)
were unable to identify gifted and talented youth. Initially, there were
concerns about the schools’ ability to attract sufficient numbers of students
for the program; those fears have proved to be unfounded. Macy schools
were able to attract more than 100 young people to their rigorous academic
programs that emphasized science, mathematics, and language skills. In
addition, new classes are being enrolled in several schools, and “in each
setting there is growing interest and demand for a more rigorous curric-
ulum” (Bleich, 1986, 1987).

Extensive in-service training has taken place, and curriculum develop-
ment has been a collaborative activity among high school teachers, BioPrep
staff, and selected university faculty. Tutorials, enhanced science labora—
tories, and independent study have been offered at the schools; bimonthly

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 171

Saturday sessions and 6—week summer programs have been held at the
University of Alabama.

The Macy Foundation reports that more than 1,200 students have en-
rolled in their projects. It estimates that more than 4,500 students will be
enrolled in grades 9 through 12 when the programs are fully established
and that schools will graduate 700 college-prepared minority students each
year.

Other high schools in the project report results similar to the Alabama
experience, lending credence to the potential of a model that blends public
and private resources to produce systemic changes that can be institution—
alized for long-lasting beneﬁt.

Lessons That Have Been Learned

More than 20 years of experience in attempting to increase the number
of minority allied health professionals suggest four areas that should be
targeted for action:

academic preparation, especially in the sciences and mathematics;
knowledge of allied health careers and the promotion of minorities;
ﬁnancing of institutions and students; and

linkages and afﬁliations in training and employment.

Despite efforts of the federal government and individual institutions,
the barriers to allied health careers for minorities that were cited in the
early 19705 remain serious problems. Can lessons gleaned from past efforts
inform policymakers and educators about what kinds of investments need
to be made in the future, where they will be most productive, and which
stakeholders can lead and contribute to greater success?

A cademic Preparation

Astin (1985) notes that minority underrepresentation in engineering,
biological sciences, the physical sciences, and mathematics can be linked to
low levels of academic preparation in mathematics and science prior to
college enrollment. Academic preparation is also the central issue that
affects the size and quality of the minority applicant pool for allied health
training. Allied health deans and program directors ﬁrmly believe that
streams of qualiﬁed minority applicants cannot be relied upon until aca—
demic deﬁciencies are substantially reduced (Committee/staff interviews,
1987; The Circle, Inc., 1987).

HCOP grantees typically have focused on strengthening the skills of
disadvantaged students in communications, mathematics, and the sciences,
with 6- to 8-week summer enrichment and tutorial programs the usual

172 ALLIED HEALTH SERVICES

interventions. Although there is partial evidence (La Jolla Management
Corporation, 1984) that such interventions can work, the conventional
wisdom is that the emphasis on mathematics and science should begin as
early as possible, starting at or even before junior high school (Bisconti,
1980; National Commission on Allied Health Education, 1980; Flack, 1982;
Lajolla, 1984; The Circle, Inc., 1987; Mingle, 1987). Perhaps allied health
schools could gain more in the long run by helping to create alliances with
others 1n the community to attack the root causes of poor academic pre—
paredness.

Allied health schools generally draw their students from known “feeder”
sources. Strengthening academic preparation at the secondary school level
and in other major feeder schools (e.g., community colleges) can contribute
to lasting improvements in the quality of their applicant pools; it can also
inﬂuence curriculum improvement at feeder schools and bring greater
visibility to allied health career opportunities. At the same time, early ac-
ademic and career counseling, a compounding factor (Committee/staff in-
terviews, 1987; La Jolla, 1984; The Circle, Inc., 1986), can be enhanced.

The Josiah Macy, jr., Foundation provides an excellent example of what
can be accomplished if students are introduced to intense academic skills
improvement programs early. Macy’s success also offers an example of
what can be accomplished by approaching problems from a broad per—
spective. The foundation incorporated a wide variety of resources and
addressed areas other than the student’s grade point average. It also con-
centrated on raising school administrators’ and teachers’ expectations of
students, educating parents, acting as a liaison to establish collaborations
between colleges and public secondary schools, and raising students’ self-
esteem.

Knowledge About emd the Promotion of Allied H eall/z Professions

Information plays a role both in attracting minority students to careers
and in keeping them through training. Informing minorities about the
wide range of allied health occupations and promoting these ﬁelds as career
options are important steps in attracting minority students to these profes-
sions.

Educators believe that better information about an occupation’s training
and practice is crucial to the relatively high attrition rate of minority stu-
dents in the ﬁrst year of professional training. Such information is not
easily acquired, however. Allied health professions are not widely men-
tioned in the media, nor are the contributions of allied health occupations
to health care delivery explained.

Those interviewed for the study reported that information dissemination
through career days, the distribution of brochures, and active recruitment

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 173

is most effective when coupled with formal and informal linkages with
feeder high schools and colleges. One school that recently began recruiting
through churches reported that they were a rich and largely untapped
source of minority allied health applicants (Booker, 1987).

Research data and the experiences of recruiters suggest that the following
factors should be taken into account in shaping effective information dis-
semination and promotion campaigns (The Circle, Inc., 1987; Mingle,
1987):

O Minority allied health students are likely to be older than liberal arts
students; they are also more likely to have children.

0 Students who demonstrate potential in high school or community
colleges may make up a greater percentage of the applicant pool than high
achievers who are already being heavily recruited for medicine, engineer-
ing, and other professions.

0 Community colleges can become a good source from which to draw
students interested in earning a bachelor’s degree, especially if linkage
arrangements that incorporate approaches to sharpening critical skills and
increasing students’ awareness of career options are implemented.

0 Persons who are disenchanted with their current occupations in other
ﬁelds may be seeking an opportunity to pursue a new, more challenging
and rewarding career.

Financing for Institutions and Students

Deficiencies in academic preparation are fairly widespread among mi-
nority allied health students, and deans of allied health schools expect this
shortcoming to continue in the near term. They believe that financial
support will continue to be needed for activities that help struggling stu-
dents remain in school. These activities include prematriculation summer
programs, faculty and peer tutoring and counseling, computer-aided learn-
ing assistance or instruction, and curriculum improvement/faculty devel-
opment in feeder schools.

Deans of allied health schools have concluded that external support, such
as that provided by HCOP, is essential to underwrite some of these insti—
tutional expenses (The Circle, Inc., 1987). In general, intensive minority
recruitment and retention activities are supported, at least in part and
frequently at a substantial level, by external funds. HCOP has been pre-
dominant here for all activities except curriculum improvement in allied
health training programs. A 1984 assessment of HCOP-supported pre-
paratory activities (i.e., preliminary education, entry facilitation, and reten-

1 74 * ALLIED HEAL TH SER VICES

tion) concluded: “Since by far the largest expenditures for HCOP are for
preparatory activities, it is essential that HRSA [Health Resources and
Services Administration] and the grantees focus special attention on pro-
viding those preparatory activity services that produce the greatest beneﬁt
to the objectives of the HCOP program” (La Jolla Management Corpo-
ration, 1984).

Since 1978 funding for allied health under HCOP has increased as a
proportion of the total HCOP investment, but total funds for the program
as a whole have diminished and authorized purposes have been more
narrowly defined. For example, there are currently no federal programs
that support minority allied health faculty development or curriculum im-
provement in minority schools or in nonminority schools that View curric-
ulum changes as one way to recruit and retain more minorities.

The preeminent Minority Access to Research Careers (MARC) and Mi—
nority Biomedical Research Support (MBRS) programs, the oldest of the
existing minority-oriented programs administered by the National Insti-
tutes of Health (NIH), support these kinds of activities, as do other, similar
programs. Such programs have been credited with substantial contributions
in increasing research, research training, and the number of researchers
in institutions that train large numbers of minorities. Included 1n this cluster
are signiﬁcant numbers of traditionally and predominantly minority schools
(Garrison and Brown, 1985; Gonzales, 1987).

Along with a lack of institutional support, insufficient student financial
aid is also seen as a deterrent both to minority student recruitment and
retention. Allied health deans cited lack of funds as a major reason for
student attrition. Many minority allied health students are older and have
children; many of them ﬁnd that school schedules generally do not permit
them to continue working. In such circumstances, financial aid is a crucial
factor in their persistence in working toward a degree. Bisconti (1981)
notes that “a degree in an allied health major frequently is more expensive
than a liberal arts degree.” Tuition costs may not be higher, but there may
be additional costs for clinical education and materials or equipment. Fur-
thermore, the period of training (both preprofessional and professional)
may be longer.

Although states are investing in educational support for minority health
professionals, the size of these investments varies widely, and most state
aid is targeted toward medicine and dentistry. The committees’ interview
respondents felt that states needed to provide more student ﬁnancial aid.
Models that have successfully contributed to shifting the distribution of
medical and dental professionals (e.g., the National Health Service Corps,
loan forgiveness, AHEC) offer incentives for minority professionals to work
in underserved areas. These are strategies that may be equally effective
for allied health practitioners.

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 175

Linkages and Aﬂiliatiom in Training and Employment

Linkages among colleges and high schools are playing an increasingly
important role in encouraging the training of minority allied health profes—
sionals. Directors of allied health programs with and without HCOP grants
acknowledge their value in recruiting students. It appears that linkages
with high schools for recruitment purposes are becoming formalized, per-
haps in response to HCOP’s continued emphasis on such linkages since
1981. Data show that there are more linkages between schools and 4-year
historically black colleges and universities than between high schools and
community colleges. However, some schools that today lack community
college linkages report plans to explore these arrangements. Linkages ap-
pear to work well when there is shared commitment and mutual beneﬁt,
regardless of whether the arrangement is formal (as in a written agreement
that speciﬁes responsibilities and beneﬁts) or informal (a working relation-
ship).

The predominantly minority schools contacted by the committee re—
ported no difﬁculties in finding adequate clinical placements for their stu—
dents. These placements were most often in areas with large minority
populations. Today, programs are quite dependent on hospitals for place-
ments and have limited experience with other kinds of sites for student
clinical training; thus, clinical training may be threatened if hospital rev-
enues are reduced. Yet, several schools reported that clinical sites pay the
tuition for students they accept for clinical placements, usually because the
hospital is interested in hiring students who train with them. This interest
should help sustain afﬁliation agreements between schools and hospitals,
especially if workers are scarce.

N0 strategy for signiﬁcant increases in minority participation in the allied
health professions will be successful unless it directs resources toward the
major barriers to minority participation and involves the complete spectrum
of interested parties, both in government and in the private sector. Minority
recruitment efforts must begin before high school. Academic institutions
must offer support services for retention and seek to promote educational
mobility. To succeed in the long term, these efforts must be made integral
to the mission of the educational institutions.

Ultimately, success will depend on the ability of educational institutions
to make a long-term commitment to integrating minority recruitment and
retention into the fabric of their allied health programs. The erosion of
federal support for this objective would undermine those in the education
community who are struggling to gain or maintain such a commitment to
minority allied health education. The committee endorses the objectives
of HCOP and believes that funding levels must be maintained at least at
current levels.

176 ALLIED HEALTH SERVICES

MAINTAINING AND EXPANDING
EDUCATIONAL CAPACITY

The future supply of new graduates in allied health ﬁelds depends not
only on students’ careers but also on the maintenance and expansion of
educational opportunities.

Hospital-sponsored allied health education programs suffered more clo-
sures than any other types of programs. Between 1982 and 1986, 315
hospital-sponsored programs closed, compared with a small number of
proprietary school closures. By contrast, there was a net increase in pro-
grams at community colleges (100 new programs, or 9.6 percent) and junior
colleges (26 new programs, or 4 percent) (CAHEA, 1987a). Table 5-3 shows
the net change between 1982 and 1986 in selected CAHEA-accredited
allied health programs. Much of the decline in allied health educational
capacity can be attributed to the closing of hospital-based training pro-
grams—principally programs in laboratory and radiologic technology. Pro-
grams that have the largest number of withdrawals from CAHEA
accreditation (and that are presumed by CAHEA to have closed) are med-
ical technology (116), radiography (103), and respiratory therapy technol-
ogy at the certificate level (29) (CAHEA, 1987b).

Among programs that are not accredited by CAHEA, physical therapy
grew rapidly—from 84 baccalaureate programs in academic year 1980—
1981 to 97 programs in 1985—1986; master’s degree programs increased
from 9 to 14 during the same period (American Physical Therapy Asso-
ciation, 1987).

TABLE 5-3 Changes in the Number of CAHEA—Accredited Programs
in Selected Allied Health Fields Between 1982 and 1986

Number of Number of

 

 

Programs Programs Percentage of

CAHEA-Accredited Programs in 1982 in 1986 Change
Negative Change

Medical laboratory technician (certiﬁcate) 73 47 — 35.6

Medical technologist 639 516 — 19.2

Radiographer 790 701 — 11.3

Respiratory therapy technician 188 169 — 10.1

Nuclear medicine technologist 138 128 — 7.2

Medical record administrator 57 53 —7.0
Positive Change

Medical record technician 85 87 2.4

Occupational therapist 56 63 12.5

Medical laboratory technician (associate

degree) 187 214 14.4
Respiratory therapist 204 235 15.2

 

SOURCE: CAHEA (1987a).

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 177

There is no clear evidence that capacity in higher education institutions
is in serious jeopardy. Nevertheless, program closings, coupled with fears
of a decline in the number of applicants, have heightened allied health
program directors’ feelings of vulnerability. These feelings, which were
expressed by educators to the committee during its deliberations, arise from
a threefold concern: (1) allied health education will not be able to maintain
its foothold in research universities; (2) clinical education sites will grow
scarce; and (3) ﬁnancially stressed educational institutions of all types, view-
ing allied health as a costly endeavor, will close allied health programs.

Given the nation’s projected need for allied health personnel and their
relatively short stay in the allied health work force, any serious erosion of
the education sector’s capacity to supply the nation with allied health per-
sonnel must be avoided. The question for public policy action is whether
vulnerability poses a real and present danger that cannot be addressed by
market forces alone. If government intervention or private efforts, or both,
are required, what actions will offer the greatest return on public and
private investments? To answer this question, we must ﬁrst understand the
roles of various important decision makers and how their actions can
strengthen 0r weaken allied health education programs.

Who Inﬂuences Educational Capacity Decisions?

The decisions to open or close allied health programs or to expand or
contract enrollments are ostensibly in the hands of educational institutions
themselves. Typically, a dialogue occurs between a dean or department
head and the chief administrator for academic affairs about the desirability
of adding programs or the need to close or reduce the enrollment level of
a program. The remarks of one university president who was responsible,
earlier in his career, for manpower projections at one of the allied health
professions associations provide some interesting insights into the context
of this dialogue:

It obviously becomes extremely difficult for a university president to justify the
continuation of this or any other program when student demand has moved else-
where, say, to real estate, and when the dean of the school of business is clamoring
for those scarce resources to be diverted to their front. Further, since the average
age of my faculty is only 49, natural attrition does not facilitate resource shifts.

It would be easier for me to justify maintenance of high cost programs if external
support were still ﬂowing to my campus; however, as you are well aware, there has
been a steady decline in the amount of federal dollars available for health education.
Therefore, academic administrators are on the horns of a dilemma, and now, like
health care administrators, we must monitor the environment continuously and
respond to changes as never before. Strategic planning is the name of the game.
Universities can no longer afford to be all things to all people. (Perrin, 1987)

178 ALLIED HEALTH SERVICES

Decision making does not take place in isolation, and many parties can
be involved in precipitating a dialogue and inﬂuencing its course. These
parties include federal agencies such as the Bureau of Health Professions,
state higher education and licensing agencies, state political leaders, ac—
crediting bodies, professional associations, and local health care providers.
At times, the pressures exerted by these parties and conversely, the op-
portunities they have offered schools, through grants, for example, so
overwhelm institutional autonomy that it is difﬁcult to discern where con-
trol lies. ,

The issue of control is important: by understanding the distribution of
authority over allied health education, we can identify how the forces that
shape decisions about educational capacity can be influenced to accomplish
public policy goals. These goals encompass not only the size of enrollments
but the quality of education, its content, and the ability of the educational
system to add to the nation’s work force.

The Federal Role

A major, direct inﬂuence on the development of allied health manpower
training capacity has been the federal Bureau of Health Professions and
its predecessor organizations.

In 1966, not long after Congress enacted federal education funding for
medicine, osteopathy, dentistry, veterinary medicine, optometry, podiatry,
and pharmacy in one law and nursing under another authority, it also
provided education funding for 13 allied health ﬁelds. The Allied Health
Professions Personnel Training Act offered ﬁve types of grants:

1. Construction grants for training centers and afﬁliated hospitals.

2. Basic improvement grants awarded on the following formula: $5,000
times the number of eligible curricula in the center plus $500 times the
number of full-time students receiving training.

3. Grants to support traineeships for allied health personnel to become
teachers, administrators, or supervisors or to serve in allied health spe-
cialities.

4. “New methods” grants to allied health training centers for projects
to develop, demonstrate, or evaluate curricula for the training of new types
of health technologists (US. Department of Health, Education, and Wel-
fare, 1979).

5. Special improvement grants to support projects or centers that would
provide no fewer than three curricula with the aid of this funding.

Table 5-4 shows the funding history of this law and its successor pieces
of legislation. Although no federal programs have speciﬁcally supported
allied health training since 1981, allied health students and schools are

TABLE 5-4 Division of Associated and Dental Health Professions" Grants, Cooperative Agreements, and
Contracts Awarded (in dollars) in the Allied Health Area, Fiscal Years 1967 through 1986

 

 

Fiscal Advanced Training Special Special Basic

Year Traineeships Institutes Improvements Projects Improvements Other Total

1967 241,977 0 0 0 3,285,000 0 3,526,977
1968 1,203,648 0 0 799,507 9,750,000 0 11,753,155
1969 1,549,772 0 0 1,225,000 9,750,000 0 12,524,772
1970 1,538,064 0 0 1,231,938 9,701,000 0 12,471,002
1971 2,460,851 482,838 0 4,482,617 9,701,000 0 17,127,306
1972 2,585,936 324,064 10,500,000 7,628,384 0 0 21,038,384
1973 1,951,598 1,139,555 7,000,000 5,639,408 0 0 15,730,561
1973" 0 0 10,500,000 0 0 0 15,999,947
1974 2,563,000 999,888 16,000,000 10,126,537 0 0 29,689,425
1975 2,606,713 956,267 10,192,034 6,869,220 0 0 10,624,234
1976 2,563,000 1,000,000 10,499,999 8,197,432 0 0 22,260,431
1977 2,331,580 638,312 8,910,000 8,406,537 0 0 20,286,429
1978 1,443,562 924,070 0 14,345,813 0 0 16,713,445
1979 1,493,949 1,004,907 0 8,151,264 0 0 10,650,120
1980 887,062 0 0 4,251,671 0 738,961‘ 5,877,694
1981 0 0 0 508,143 0 364,516‘ 872,659
1982 0 0 0 0 0 0 0
1983 0 0 0 0 0 0 0
1984 0 0 0 0 0 908,550'I 908,550
1985 0 0 0 0 0 883,525" 883,525
1986 0 0 0 0 0 0 0
Total 25,420,712 7,469,901 73,602,033 87,363,418 42,187,000 38,101,018 274,144,082”

 

“Prior to 1983, the agency was known as the Division of Associated Health Professions.

bReleased impounded funds.

‘Military Experience Directed Into Health Careers (MEDIHC) cooperative agreement funds.

dGrants for allied health personnel in health promotion and disease prevention.

eThe grand total includes contract award amounts; contract amounts awarded by fiscal year are not available at this time, however.

SOURCE: Bureau of Health Professions Health Resources and Services Administration, unpublished data. 1987. Rockville, Md.

6L1

180 ALLIED HEALTH SERVICES

eligible for funds under several general health professions education au-
thorities, including

0 the federally-insured HEAL Student Loan Program;

0 educational assistance to disadvantaged students; and

0 health professions special initiatives (grants for special projects in areas
such as health promotion and disease prevention; curriculum development
in health policy, clinical nutrition, and the application of social and behav-
ioral services to the study of health care delivery; the development of
mechanisms for ensuring the competence of health professions; and the
development of instruction, including clinical affiliations, in geriatrics).

Efforts to assess the impact of federal funding have been stymied by a

lack of data. A major federal report on allied health concluded the follow-
ing:
It appears that it [federal funding] added impetus to a trend that was already
underway . . . much of the private sector growth in educational programs that
occurred between 1966 and 1971 without allied health grant support may have
occurred in expectation of federal assistance. Quite apart from the question of the
relative importance of federal support in increasing allied health manpower output
is the problem of determining what the increase was and where it occurred. Prior
to establishment of a federal role in allied health manpower, there was insufficient
interest in the problems to allow the collection of data on educational programs.
Not until 1972 was reliable information obtained on the type and amount of training
offered by colleges and universities. Some collegiate program growth occurred at
the expense of hospital-based programs and on-the—job training, another factor for
which there are no reliable data. (Bureau of Health Manpower, Health Resources
Administration, 1979)

Other segments of the federal government have also played roles. The
Health Care Financing Administration, through the Medicare program,
has provided support for clinically based education. The Department of
Education has helped through its general support of higher education loans
and scholarships and in its specific provision of vocational-technical train-
ing. The Veterans Administration and the military services have also played
a part in civilian training as they train personnel for their own needs. Finally,
the Department of Labor has been concerned with entry-level occupations,
offering training through the Comprehensive Employment Training Act
(CETA) program and later through the job Partnership and Training Act
(] PTA).

The State Role

Through their involvement in higher education financing and regula-
tion, states are a major force in determining the number and distribution

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 181

of allied health programs. In 1976 (the last year of complete data), 71
percent of public collegiate institutions had at least one allied health pro-
gram, but only 36 percent of private schools offered allied health education
(National Committee on Allied Health Education, 1980).

The propensity to invest in allied health education depends in part on
the health of the state’s economy. In one of its workshops the committee
explored decision making in three states—Texas, Illinois, and New York.
Participants included representatives of higher education coordinating au-
thorities, general collegiate administrators, and allied health school deans
from different types of institutions. They described decision making and
a sense of vulnerability that was related to the economic health of their
regions.

Allied health program administrators in Texas, where tax revenues have
been falling because of the declining oil industry, felt at greatest risk. The
Texas allied health educators believed themselves to be the first line of
defense against medical school cutbacks.

The economic situation was somewhat better in Illinois, but overall state
higher education cutbacks were forcing state college systems to plan their
responses to budget cuts if a pending tax increase did not occur. One
school system, having already raised tuition the previous year, had directed
its deans to consider the implications of a 5 percent budget reduction. The
options available to one allied health dean included the following: (1) not
filling vacant faculty positions, (2) offering some courses once instead of
twice that year, (3) canceling planned equipment purchases, and (4) closing
the school’s physical therapy program, which needed more space.

At the time of the workshop, New York State deans and policy officials
were focused not on budget cuts forced by the state’s economic picture but
on the state’s responsibility for ensuring an adequate supply of health care
personnel. A state health department task force had recently been formed
to explore “critical shortages” in nursing, home health care, and physical
therapy services. One issue prompting the creation of the task force was
the inability of state chronic care facilities to recruit therapists. Deans at-
tending the committee’s workshop identified faculty shortages as a major
impediment to expanding education programs and enrollments in physical
and occupational therapy.

Statewide planning frequently occurs under the auspices of state higher
education coordinating bodies, which are responsible for approving new
education programs. In evaluating new programs, the coordinating bodies
consider such issues as geographic maldistribution of programs and prac-
titioners and the impact of new programs on minority participation. De-
cision makers who participate in this policy arena often must be reconciled
to the fact that the politics of higher education planning (deciding, for
example, which among competing institutions should receive the new pro-

182 ALLIED HEALTH SERVICES

gram) may not lead to the conclusions that make the most sense from a
health planning standpoint.

States emphasize different values in their review of criteria for new
programs. Missouri notes that its “State-wide review is principally interested
in the state’s need for programs and services, and resource allocation issues.
That is, the statewide need for particular programs and the appropriate
means of financing these needs to assure Missouri’s citizens ﬁnancial access
to quality educational experience” (Missouri Coordinating Board for Higher
Education, 1986). In contrast, Texas has stated that “The expenditure of
public tax funds for educational programs in any occupational area is a
matter of public policy directed at meeting a public need that cannot or
will not be met otherwise. Student interest is not the major concern for
expenditure of public tax funds for an occupational training program”
(Allied Health Education Advisory Committee, 1980).

The ability of state coordinating bodies to enforce their resource allo-
cation policies varies. Some state authorities may only be able to apply
“jawboning” tactics to inﬂuence institutional decisions. In some cases, battles
are fought during the state legislature’s higher education budgeting pro—
cess—through a specific line-item request for a new program, for example.
Depending on state political tradition, legislators may choose to wield in-
ﬂuence in favor of constituent educational institutions and in response to
lobbying efforts. More often, however, the survival of allied health pro-
grams is brought into question when academic institutions find themselves
forced to reallocate institutional resources as a result of a budget crisis. In
some states, higher education coordinating/governing bodies have statutory
review powers for new programs.

The Private Sector Role

The private sector role can be seen in the activities of accrediting bodies,
professional associations, and foundations.

Accrediting Bodies There are a multiplicity of issues surrounding who
should control accreditation, how it should be structured, and whether it
could be a less costly process. This discussion, however, will focus on ac-
creditation standards, which have a major impact on collegiate decision
making about new or expanded programs.

Program administrators must take into account the cost of complying
with the standards of accrediting bodies and the recommendations of site
review teams. For example, programs sometimes close because they cannot
maintain the student—faculty ratios, equipment, or space required by an
accrediting body. Often, there is a clash between the accrediting body
(which believes its essentials ensure basic minimum standards) and gen-

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 183

eralist academic administrators (who see site review recommendations as
a tool to be used by departmental chairmen to get more support for their

programs).

Professional Associations Historically, much of the educational activity of
allied health professional associations has been in promoting the shift of
educational programs from hospitals to academic institutions. Once this
shift was accomplished, an association’s interest often centered on raising
the entry level of the profession or on creating assistant-level categories of
personnel.

Today, associations’ educational activities range more widely. They might
include consultation to academic institutions contemplating new program
offerings, workshops for administrators and faculty, student recruitment
programs, and the maintenance of education data bases. Some associations
have assumed quasi-regulatory functions in the education accreditation
arena. For example, accreditation responsibilities for dietetics, physical ther-
apy, and speech—language pathology and audiology are handled through
independent entities operating in conjunction with the professional asso-
ciations. It should be noted, however, that some of the allied health ﬁelds
do not have a well—organized professional association that can engage in
educational activities.

Supplementing the work of the associations are the American Society of
Allied Health Professions and the National Society of Allied Health—two
umbrella organizations that cut across disciplinary lines in an effort to help
their members address educational issues common to most ﬁelds.

Because of an extensive literature and the activities of the Federal Trade
Commission in questioning the role of the American Medical Association
in limiting the supply of physicians through medical education, it is rea-
sonable to raise the question of whether allied health associations inﬂuence
the supply of practitioners in their respective ﬁelds, restricting entry as a
means of enhancing the economic status of their members. An investigation
to determine such inﬂuence, however, was beyond the scope of this study.

Private Foundations Complementary to the role of federal and state sup—
port is the contribution of philanthropy in generating experiments in allied
health education. Principal among the foundations is the W. K. Kellogg
Foundation, an organization that over many years has spurred institutional
development and leadership activities and studies of allied health ﬁelds.
Currently, the foundation is supporting a clearinghouse at the University
of Alabama to clarify and promote the concept of multicompetency in
allied health as well as supporting several activities of the American Society
of Allied Health Professions.

184 ALLIED HEALTH SERVICES

Why Is Allied Health Education Vulnerable?

As indicated in the previous section’s review of federal, state, and private
roles, the era of direct efforts to expand the allied health education en-
terprise has ended. Yet the day-to-day business of federal, state, and private
decision makers continues to shape allied health education. Federal Med—
icare reimbursement policy, state higher education budgeting and regu-
lation, interest groups in pursuit of enhanced professional status, and
educational accreditation are all powerful inﬂuences on the future of allied
health education. How stable educational institutions will be in the future
will depend on their ability to compete for higher education resources with
other, more entrenched academic programs whose graduates may also be
in high demand.

Maintaining Ground in Academia

A number of prestigious institutions—the University of Pennsylvania,
University of Michigan, Emory University, and Stanford University, for
example—have closed allied health schools and programs. A fundamental
component of the rationale for closure appears to have been that the
preparation of allied health practitioners did not sufﬁciently contribute to
the aspirations of a research university seeking to concentrate its resources
in areas of strength. As allied health deans see some of the most noteworthy
programs close, they grow apprehensive about the future of their own
programs. They are also concerned about the future of allied health pro-
grams because the programs lack the capacity to foster research and pro-
duce teachers and academic leaders (Broski et al., 1985; Hedrick, 1985).

Although it is difﬁcult to document the fragile condition of allied health
education, the committee believes there is some basis for the deans’ ap-
prehension. Furthermore, the committee is concerned that closures have
signaled to academic decision makers and public officials alike that allied
health education may not be a sound investment for scarce educational
dollars.

As Table 5—5 (which is based on 19705 data from the National Com-
mission on Allied Health Education) shows, these programs have long
existed in almost every type of collegiate institution. The committee believes
that there is no generic or inherent quality that disqualiﬁes allied health
education from life on any campus in the nation. The diversity and evo-
lution of the many occupations suggest that some are more suited than
others to various academic settings and degree levels. Yet the conclusions
that are drawn today about a given field may change tomorrow as knowl-
edge and practice evolve. Each type of collegiate setting has its advantages
and disadvantages. Generally speaking, for example, academic health sci-

,

TABLE 5-5 Percentage of Collegiate Institutions with Allied Health Programs in 1975—1976, by Carnegie

Classiﬁcation of Institutional Type

 

Number of Such
Institutions in the
Type of Institution United States

Number and Percentage with
Allied Health Programs

 

Number

Percentage

Percentage of All
Allied Health
Programs in Such
Institutions

 

Research universities I 31
Leading universities in terms of federal
ﬁnancial support for academic science and
award at least 50 Ph.D.s annually (and M.D.s
if a medical school is on the same campus).

Research universities II 47
Among the leading 100 institutions in terms
of federal financial support and award at
least 50 Ph.D.s (and M.D.s if applicable).

Doctorate-granting universities I ‘ 56
Award 40 or more Ph.D.s (and M.D.s) or
received at least $3 million in total federal
support in either 1969—1970 or 1970—1971.
No institutions are included that grant fewer
than 50 Ph.D.s (or (M.D.s).

Doctorate-granting universities II 30
Institutions awarding at least 10 Ph.D.s.

47

41

47

27

92

87

84

90

7.95

2.72

Continued

981

TABLE 5-5 Continued

 

Type of Institution

Number of Such
Institutions in the
United States

Number and Percentage with
Allied Health Programs

 

Number

Percentage

Percentage of All
Allied Health
Programs in Such
Institutions

 

Comprehensive universities and colleges I
Institutions offering a liberal arts program
and several others (e.g., engineering,
business administration) that have at least
two professional or occupational programs
and enroll at least 2,000 students. Many
have master’s programs and, at most, limited
doctoral programs.

Comprehensive universities and colleges II
State colleges and some private colleges that
offer a liberal arts program and at least one
professional or occupational program (e.g.,
nursing or teacher training, mainly with a
degree in education).

Liberal arts colleges I
Highly selective or among the 200 leading
bachelor’s-granting institutions in terms of
numbers of graduates receiving Ph.D.s at 40
leading doctorate-granting institutions.

Liberal arts colleges II
Other liberal arts colleges, many of which
are extensively involved in teacher training,
granting degrees in arts and sciences rather
than in education.

380

217

126

474

302

135

27

243

79

63

21

51

22.76

at
M
Cl

0.75

8.33

981

Two-year colleges and institutions

Theological seminaries, bible colleges, and
other institutions offering degrees in religion

Medical schools and medical centers
Includes only those that are listed as
separate campuses in USOE Opening Fall
Enrollment.

Other separate health professional schools

Schools of engineering and technology
Technical institutions are included only if
they award a bachelor‘s degree and if their
program is limited exclusively or almost
exclusively to technical ﬁelds of study.

Schools of business management
Included only if they award a bachelor’s or
higher degree and if their program is
limited exclusively or almost exclusively to a
business curriculum.

Schools of art, music, design
Schools of law
Teachers colleges

Other specialized institutions
Includes graduate centers, maritime
academies, military institutions (lacking a
liberal arts program), and miscellaneous
others.

SOURCE: National Commission on Allied Health Education (1980).

1,135
277

29
47

16
28
35

00011010

24
21

37

13
18

35.18
0.07

3.95

0.17
0.5

0.3

0.05
0.05
0.32
0.17

L81

188 ALLIED HEALTH SERVICES

ence centers have easier access to clinical resources and a wide range of
opportunities for interdisciplinary experiences. However, as reported to
the committee, the latitude for decision making and creativity of program
design by deans and program directors has traditionally been more limited
in academic health science centers than in schools of allied health that are
independent of such centers. Community colleges shine in their ability to
attract to diverse student populations who are job oriented. Educational
programs there are tailored to suit the needs of employers and students
in a given local community.

To guide institutions in deciding whether to continue or start allied health
education programs, the Southern Regional Education Board (1980) sug-
gests that the following six questions be considered:

1. Mission Is the program consistent with the institution’s philosophy
and purpose?

2. Employment Will graduates be able to secure employment and will
that employment satisfy the local, state, regional, or national mission of the
institution?

3. Accreditation Is the institution willing to invest in a program, given
the resource consumption implicit in achieving accreditation?

4. Students Will there be sufﬁcient enrollment over a sustained period
of time?

5. Budgetary concerns Is the institution prepared to adopt programs in
which clinical components may require equipment, supervision, and costs
that often exceed those of other types of academic programs?

6. Faculty Is there a sufﬁcient faculty pool on which to draw? What
resources will be necessary to attract qualiﬁed individuals to teach?

Today, allied health education appears vulnerable on all but the ‘em—
ployment demand’ criterion. The key to improving allied health’s bargain-
ing position in academia is to demonstrate value to the parent institution
that is striving to fulﬁll its mission of scholarship or community service.
The recommendations that follow are designed to address some of the
problems that prevent allied health programs from competing effectively
for institutional resources and thus endanger their viability.

Faculty Shortages

Because many allied health ﬁelds are relatively new to collegiate envi-
ronments and have grown rapidly in the past 2 decades, allied health
educational programs often face both quantitative and qualitative problems
in ﬁlling faculty positions. In physical therapy, for example, the number
of accredited university programs grew from 48 in 1970 to 113 in 1986.
The supply of faculty does not appear to have kept pace. A 1985 survey
of academic administrators in these programs reported a need for 152

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 189

additional faculty simply to meet current demands (American Physical
Therapy Association, 1985). As a result, many programs rely heavily on
part-time lecturers without regular faculty appointments, faculty from sci-
entiﬁc disciplines who do not hold professional qualiﬁcations in the clinical
ﬁeld, and professionals who lack the academic credentials that are tradi-
tionally expected of university faculty. For example, in its faculty survey
the American Physical Therapy Association reported that only 28.2 percent
of full-time faculty in physical therapy programs had doctoral degrees.
This proportion was in clear contrast to national data that showed that 54.9
percent of all faculty teaching in institutions of higher education had doc-
torates (Newman, 1985). The recruitment of qualiﬁed new faculty is se-
riously hampered by the very limited pool of candidates. Even in relatively
mature occupations such as occupational and physical therapy, professional
associations report that only about 1 percent of all members have doctoral
degrees and just over 24 percent have master’s degrees (American Physical
Therapy Assocation, 1987; American Occupational Therapy Association,
1987).

In a survey of 124 medical record education programs (which constitute
more than 80 percent of all programs), the majority employed only one
or two additional faculty members besides the program director; no pro—
gram had more than four full-time additional faculty. Only ﬁve of the
directors of these schools had a doctorate. Among the 53 full—time faculty
members in university-based programs, only 2 had doctorates, 33 had
master’s degrees, and 18 had baccalaureates as their highest academic de-
gree (Amatayakul, 1987).

Although some allied health professionals are enrolled in master’s and
doctoral degree programs, the lack of ﬁnancial aid and the relatively low
earnings of allied health clinicians force most of them to carry out this
advanced study on a part-time basis over a long period. Lack of funding
has also constrained the development of graduate programs in several allied
health disciplines. Although advanced study in such related disciplines as
physiology, psychology, or education beneﬁts allied health faculty, the lack
of graduate programs in their own disciplines has limited the number of
allied health faculty who are active scholars in the ﬁeld in which they have
the greatest teaching responsibility.

The options for producing faculty efﬁciently should be explored to max-
imize faculty development resources. The American Occupational Therapy
Association has had some success in targeting faculty development efforts
toward clinical faculty who might be inclined to pursue full-time teaching
appointments (S. Presseller, American Occupational Therapy Association,
personal communication, 1987). Another approach would be to focus at—
tention on streamlined allied health certiﬁcate programs that give individ-
uals with doctorates in other academic disciplines the opportunity to gain

190 ALLIED HEALTH SERVICES

a practice credential for teaching purposes. Holcomb and colleagues (1987)
have described a partnership between Baylor College of Medicine, Texas
A&M University, and the University of Houston that offers programs in
allied health teacher education and administration that have been pro-
ductive in supplying faculty nationwide.

The rationale for a federal role in faculty development in allied health
is similar to the justiﬁcation for federal support of family practice programs
in medicine. From 1972 through 1984, federal grants of more than $200
million fostered the growth of graduate family medicine training activities
(Health Resources and Services Administration, 1986). Like allied health,
family medicine exists today because the federal government was willing
to promote a concept that was designed to address some of the health care
system’s deﬁciencies. As a relatively new endeavor, family medicine de-
partments still lack qualiﬁed faculty and the ability to garner research funds
from traditional sources such as NIH, in part because of noncompetitive
research credentials among faculty and in part because of the low funding
priority of primary care research. Like allied health, family medicine has
yet to prove itself to the academic medical center establishment—a task
that is hindered by a reimbursement system that does not generally reward
non-procedure—oriented faculty practice.

Federal grants are being used to make the playing ﬁeld more level for
family medicine in the competitive medical school environment. Federal
investment in family practice is based on the policy assessment that primary
care needs are unmet and that these programs are a cost-effective means
of producing and distributing primary care practitioners. Similar national
goals relating to issues of rehabilitation, disease prevention, AIDS treat—
ment, and geriatrics can be well served by the support of allied health
education.

The committee recommends that federal and state governments fund
faculty development grants in allied health ﬁelds, especially in areas in
which faculty availability and lack of clinical expertise inhibit the pro-
duction of entry-level practitioners.

Closely tied to the need to improve teaching faculty is the need to advance
research in allied health. Research and other forms of scholarly activity are
inherent features of academic life. Programs that fail to give sufﬁcient
weight to academic research, along with teaching and service to the insti-
tutions, are doomed to instability over the long run. In recognition of this
fact and with the belief that the practice of any large group of health care
professionals ought to be informed by an increasing knowledge base, the
1983 IOM study of nursing recommended that the federal government
fund programs to increase the supply of doctorally prepared nurse re-
searchers and support “an organizational entity to place nursing in the
mainstream of scientiﬁc investigation” (Institute of Medicine, 1983). These

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 191

recommendations spurred the creation of the NIH Task Force on Nursing
Research and, eventually, congressional action that established the Center
for Nursing Research at NIH.

In its ﬁnal report the NIH task force concluded that the extramural and
intramural program activities then supported by NIH were consistent with
the mission of the institutes and that studies conducted with nurses as
principal investigators and studies designed to improve nursing care (but
not necessarily directed by nurses) could be fostered through a combination
of activities. These activities were intended to help train nurse researchers,
encourage greater collaboration by and interest on the part of medical
scientists in interdisciplinary work, and enhance the capability of nurses to
compete for research support (National Institutes of Health, 1984).

Although there are few data to conﬁrm the impression, it appears that
the research capability of most allied health ﬁelds is less developed than
that of nursing. In part, this increased capability of nursing may be due
to the continuing commitment to research provided by the federal Nurse
Training Act (Title VIII, Public Health Service Act) and the newly created
Center for Nursing Research within NIH. Covey and Burke (1987) offer
an additional explanation:

Because qualiﬁed faculty by the traditional standards were not available, selection
of our University faculty has often been largely from the practitioner ranks and
from those who had perhaps acquired graduate degrees in such unrelated disci—
plines as education or administration. The focus of their training has been on
technological competence and, in some cases, discipline pedagogy but has not always
included research. By virtue of their own training, deans and directors themselves
are often unable to develop the junior faculty and, in fact, too many deans and
program directors either lack an understanding of or simply ignore the tripartite
academic mission.

In later chapters of this report that deal with issues of health care man—
agement and regulation and with long-term care, the committee notes
decisions that administrators, payers, and regulators must make in the
absence of an allied health research literature. Medical scientists and other
researchers on their own will not and cannot deﬁne research priorities
from among health care services delivery issues or the clinical applications
that typically concern allied health practitioners. Although medical scientists
should be encouraged to develop collegial relationships and undertake joint
projects with allied health personnel, they are not as likely to be interested
in the outcome measurement and cost—effectiveness issues that need to be
addressed as are those who deliver the services.

Allied health ﬁelds vary in their maturity with respect to a productive
research capacity. Some ﬁelds such as dental hygiene, in which most prac—
titioners have less than a baccalaureate, are only now beginning to explore

192 ALLIED HEALTH SERVICES

the possibilities of a cadre of research leaders to build a body of knowledge
linked to a theoretical framework. This research should go beyond simple,
unrelated pilot studies. It should deﬁne dental hygiene as distinct from
dentistry and explore the efﬁciency of methods and modes of practice
(Bowen, 1988). In contrast, other ﬁelds like speech—language pathology
and audiology have many practitioners with master’s degrees and doctor-
ates and a rich history of tapping into a growing knowledge base in human
communication services and disorders. Both ﬁelds, however, share a con-
cern over the lack of relevant research ﬁnding its way to those who provide
patient services—whether it be to the communicatively impaired (Ludlow,
1986) or to those seeking preventive services from a dental hygienist.

A cadre of researchers and academic leaders is needed to advance the
scientific base of allied health practice. To accomplish this goal, insti-
tutions with strong research commitments should consider developing
programs that identify and nurture talented individuals. The committee
recommends that a federal research fellowship program be instituted to
support these activities.

is

Financing Clinical Education

The closing of hospital education programs discussed earlier in this
chapter represents more than a long-term shift from hospital-based to
academically based education. Hospitals with limited resources may reduce
or eliminate clinical afﬁliations with education programs in addition to
closing their own sponsored programs.

As clinical afﬁliates attempt to trim their costs in response to reduced
revenue, educators fear that hospitals will request remuneration for the
supervision of students or seek other means of shifting costs back to the
educational institution. As of 1987, it appears that this is not a large prob-
lem. When CAHEA (in press) queried education directors about changes
over the past 3 years in the costs of the clinical portion of their programs,
it received the following responses: 17 percent said they had experienced
signiﬁcant cost increases; 13 percent felt that program viability was threat-
ened; and 15 percent perceived that the program had become a burden
to the sponsoring institution. Only 7 percent reported a signiﬁcant change
in curriculum. Allied health educators are also concerned about long-stand-
ing proposals to constrain or eliminate Medicare payments for education.
Currently, Medicare pays hospitals for the direct educational costs of allied
health programs on a reasonable cost basis as an addition to the DRG
payment. Payments are intended for provider-operated programs and not
for afﬁliated programs in which the hospital provides part of the clinical
training in a university-based program. For the latter, the costs of the
training and its beneﬁts to the hospital are presumed to balance one an-

EDUCATIONAL POIJCY’S ROLE IN INFLUENCING SUPPLY 193

other. Since the passage of PPS, there has been some confusion over whether
the costs of jointly sponsored programs are eligible for reimbursement.

Presidential budget proposals to terminate Medicare funding for hos—
pital-based allied health and nursing education programs have added to
concerns that hospital ﬁnancial managers, who are looking for every op-
portunity to reduce institutional costs, will eliminate clinical afﬁliations
whenever feasible. To those attempting to ﬁnd ways to reduce the federal
budget, the direct support of educational programs represents an open-
ended expenditure that is insufﬁciently targeted to the most important
national human resources needs. Most often, these are thought to be the
development of greater numbers of primary care physicians and fewer
specialists.

Several recent studies sponsored by the Health Resources and Services
Administration to assess the impact of proposals to eliminate Medicare’s
educational support have provided a better understanding of the role
played by this source of educational ﬁnancing. A congressionally mandated
study of nursing and nonphysician (i.e., allied health, as deﬁned by the
study) costs in educational programs approved for Medicare reimburse-
ment, conducted by Applied Management Services, Inc., revealed that,
together, these programs cost Medicare roughly $226 million in the second
year of prospective payment. This ﬁgure is relatively small compared with
the $42.7 billion the government paid to hospitals under Part A Medicare
for the same period. The analysis of Medicare cost reports indicates that
nonphysician health care education programs cost the 514 providers in the
program a total of $167 million. Nursing programs were more expensive,
costing 547 providers $533 million (Health Resources and Services Ad-
ministration, 1987). Medicare pays only for its own share of the allowable
direct costs.

Other studies (Lewin and Associates, 1987; Mathematica Policy Research,
Inc., 1987) have conﬁrmed the observations of Applied Management Ser-
vices in interviews with the directors of hospital education programs. Ed-
ucation programs offer numerous beneﬁts to the employer, chief of which
is the opportunity to recruit future employees. Additional beneﬁts include
motivating existing staff to stay abreast of advances in their ﬁelds, and
enhancing the reputation of the hospital by providing a community service
to local educational institutions.

The committee believes that the federal government should not reduce
its support on the presumption that employers—realizing the beneﬁts of
education programs——will maintain and even increase their support. Pre-
cipitate action to cut Medicare’s educational support runs the risk of de—
stabilizing vulnerable allied health education programs. In the committee’s
View, such destabilization is not worth relatively small, short-term budget
savings. In the long run, Medicare beneﬁciaries would be harmed by lim-

194 ALLIED HEALTH SERVICES

iting clinical experience for students. Moreover, many of these costs are
likely to emerge later as potentially more costly recruitment and on-the-
job training expenses.

Therefore, the committee recommends that, until credible alternative
approaches are developed, the federal government and other third-party
payers maintain current reimbursement levels and mechanisms of sup-
port for clinical allied health education.

The Comparative Cost of Allied Health Education

Allied education programs are perceived by educational planners and
administrators to be high-cost programs. As a consequence, they can be
prime targets for institutional budget reductions by central administrative
staff. Where state higher education funding formulas do not compensate
for these higher costs, programs are exceedingly vulnerable to cost-cutting
measures when times are hard in higher education.

There has been growing recent interest in constructed cost models to
improve the ability of allied health deans and program directors to negotiate
with their central administration and explain why their unit costs may be
higher than those of other ﬁelds. These models focus on key assumptions
about faculty contact hours, faculty—student ratios, resource requirements
for clinical experiences outside the department, and faculty salaries (Free-
land and Gonyea, 1985). Although the models are useful tools for im-
proving efﬁciency and then demonstrating those improvements to academic
administrators, their explanatory power does not change the reality that
allied health education is faculty intensive, that it necessitates clinical ed-
ucation experiences requiring coordination and supervision, and that it
often has extensive laboratory and space requirements.

The recommendations that have already been made in this chapter will
help to address some of the weaknesses allied health programs have in
competing for resources. Yet these measures are no substitute for the
actions many allied health schools must begin to take to generate the rev-
enue needed to thrive. Medical schools have come to rely increasingly on
income generated from faculty practices. Although such activities may not
be appropriate or ﬁnancially advantageous for many allied health ﬁelds,
they may be so for some if they are established with sufﬁcient forethought
and expertise. The notion of generating revenue by providing services
needs further exploration, however. For example, the services provided
by allied health schools might be educational (extension courses or adult
education, for example), or they could involve innovative relationships with
industry.

To enhance the stability of allied (infealth education, national organi-
zations such as the American Society Allied Health Professions should

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 195

investigate models in which academic institutions have succeeded in
broadening their ﬁnancial base through such mechanisms as faculty prac-
tice plans, extension courses, and industry relationships. The national
organizations should also hold workshops to help institutions implement
the models and to disseminate information.

In undertaking revenue-generating enterprises, however, allied health
deans will confront and possibly exacerbate a problem they have faced
before. Faculty resources currently are stretched thin to control costs, and
the excessive teaching load leaves little time for faculty to engage in scholarly
activity, research, and college committee work. Yet these activities constitute
a major portion of the traditional evaluation criteria for faculty promotion
and tenure. Consequently, they are the preferred nonteaching activities
pursued by faculty wishing to advance their academic careers. Maintaining
state-of-the-art clinical competence further adds to the faculty’s already
excessive work load. Indeed, the committee heard a number of deans
complain of the difﬁculties their faculty members face in maintaining clin-
ical skills and of the concomitant impact of these difﬁculties on preparing
students for the labor market.

To ensure that the clinical competence of allied health faculty is main-
tained, the institutional award system must accommodate clinical compe-
tence because faculty allocate what little nonteaching time they have to
those activities that are highly rewarded. The committee recommends that
institutions that offer allied health academic programs reward and en-
courage faculty clinical competence. Clinical practice that sustains this
competence should be made a requirement for promotion.

It is noteworthy that this concern about the reward system is also one
that medical educators have been forced to confront. As the president of
the Association of American Medical Colleges has observed, “Despite the
realization that teacher—clinicians are essential ingredients of medical fa-
cilities, the need is often not recognized by the parent universities whose
appointments and promotion policies leave no niche for the clinician—
teacher to receive proper recognition” (Petersdorf, 1987).

Preparing Students for Tomorrow’s Jobs

In principle, sound educational planning would dictate that academic
institutions base their program offerings on an understanding of the knowl-
edge, skills, and socialization required of their graduates—not only for
today’s health care labor market but for the future as well. By extension,
statewide higher education planning should take into account the mix and
distribution of personnel at different educational levels that will be needed
across the state. Confounding efforts at such rational planning, however,
are a lack of clear signals from the labor market about future human

196 ALLIED HEALTH SERVICES

resource needs and continuing controversy about matching education to
the requirements of the health care delivery system.

Reﬂecting this controversy, an allied health education advisory committee
in Texas highlighted a series of concerns that often surface when such
groups View the broad spectrum of allied health ﬁelds (Allied Health Ed—
ucation Advisory Committee, 1980):

O the growing amount of narrow specialization at all degree levels;

0 the requirements of some professional groups for higher levels of
training for professional entry credentials;

I difﬁculties with the transfer of credits to implement the career ladder
concept;

0 the most appropriate levels of training for various kinds of allied health
personnel; and

O differences in the programs needed to prepare practitioners, master
clinicians, teachers, researchers, and managers.

Ironically, these issues are of concern today because, in the past, edu-
cational institutions have responded to student and employer demands.
Associate degree and certiﬁcate programs were developed to provide stu-
dents who were unwilling or unable to spend 4 years in school before
entering the work force an opportunity to enter a ﬁeld in which those
workers with traditional higher credentials were in short supply. Academic
health centers and 4-year colleges, in addition to community colleges, sought
to meet the needs of their own and local hospitals with 2—year programs.
Students with baccalaureates in other than health care ﬁelds were accom-
modated with certiﬁcate programs so they could pursue allied health ca-
reers. Students who were interested in careers in respiratory therapy, dental
hygiene, and radiography, which were principally offered at the associate
degree level, found themselves able to enroll in programs that also allowed
them to obtain baccalaureate degrees. The result of these developments
was the opening of allied health occupations to a wider range of partici-
pants.

Having accommodated the needs of different student markets and em-
ployers who were either experiencing shortages in some personnel cate-
gories or who were attempting to structure their stafﬁng with personnel
of different educational levels, the educational system is now faced, not
surprisingly, with a state of untidiness that planners ﬁnd uncomfortable.
Further complicating matters is the growing availability of graduate train-
ing. Although advanced degrees have long been accepted as appropriate
preparation for faculty, administrators, and researchers, there is greater
skepticism about graduate work when it comes to the elevation of a ﬁeld’s
entry-level qualiﬁcations or efforts to develop specialities.

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 197

The committee acknowledges this great diversity in educational quali-
ﬁcations but ﬁnds that a public policy problem requiring attention may not
exist. The diversity in and of itself is not a problem. The test of whether
specialization and changing qualifications or standards are dysfunctional
is twofold: (1) Is there wastefulness in student educational investments? (2)
Is the educational system responsive to society’s need for a manpower
supply that permits the health care system to function efﬁciently and pro-
vide care of the desired quality?

Educational Investments by Students

To open a new education program and admit a class implies a contract
with students that contains certain assurances. No school can guarantee a
student a job nor can it guarantee that skills and knowledge acquired in
its programs will be marketable in perpetuity. Nevertheless, the committee
believes that schools have the responsibility to ensure that (1) professional
education is training for a speciﬁc, “real” occupation at the end of the line;
(2) the program’s general education content is sufﬁciently balanced by
occupation—speciﬁc skills; (3) if, and when, students wish career advance-
ment through education, there is a relatively efﬁcient pathway to follow;
and (4) there is a realistic balance between the role aspirations of professions
with the realities of day-to-day work. In fulﬁlling their responsibilities to
students, educational decision makers face a number of dilemmas.

“Real” ] obs There are numerous job titles under the umbrella of allied
health. Not all of them need to have separate, formal academic programs.
Yet educators must be sensitive to changing technology and disease patterns
that may warrant such recent developments as genetic counselors and MRI
technicians.

The Southern Regional Education Board (1980) has recommended—
and the committee concurs—that academic institutions contemplating the
development of new allied health specialities ask themselves three practice-
related questions:

0 Are there any legal or professional restrictions on the new practitioners
that will tend to inhibit employers from hiring these graduates?

0 Is the new speciality sufﬁciently different from existing specialities to
justify the development of a new educational program?

0 What degree of liability does the supervisor of the new practitioners
assume?

Liberal Education Faculty in professional or technically oriented pro-
grams in higher education face a continuing struggle to reconcile the de-
mands of academia for scholarship and general education with pressures

198 ALLIED HEALTH SERVICES

from employers and accrediting bodies to prepare students for technolog-
ically demanding jobs. The argument on the side of liberal education is
that the educational program ought to be providing preparation for life
and not just for a speciﬁc job. Graduates must be prepared to respond to
the inevitable changes that will occur in society.

Many educators feel the pressure that is exerted by employers (especially
employers in ﬁelds that require familiarity with instrumentation) to inﬂu-
ence programs to produce graduates who do not need extensive orienta-
tion. Even at the community college level, which has had a strong tradition
of job orientation, there is concern about the appropriate mix of general
education and technical/clinical course work. In one small survey, 25 allied
health community college deans reported proportions of general education
to technical/clinical course work credits that ranged from 8 percent to 35
percent, with an average of 22 percent (Kaminski, 1987). In the name of
responsiveness to a changing society, general education courses compete
with pressures to incorporate such areas of study as geriatrics, computer
applications, multicompetency, and clinical experience in alternative sites
of care.

The committee is sympathetic to the dilemmas faced by curriculum plan-
ners. Yet it is also concerned that students receive an educational foun-
dation on which they can build a career if they so desire. Part of this
foundation entails developing the capacity for and an interest in lifelong
learning. A further, important benefit of such a foundation is that, if
current skills become obsolete, practitioners have a base on which they can
develop an alternative career.

Articulation Allied health dean Elizabeth King from Eastern Michigan
University describes two hypothetical students to illustrate the personal
dimensions of the problems of articulation, the process by which students
achieve upward educational transitions among academic programs (King,
1985). One student, having worked 7 years as a certiﬁed occupational
therapy assistant “with a love of the profession and a conscious decision to
build upon her current skills,” is confused and disillusioned when denied
the opportunity to transfer her professionally related course work toward
an occupational therapy degree. Meanwhile, another student with an as-
sociate degree in general studies, hearing about the good job prospects for
occupational therapists but having little knowledge about what occupational
therapists do, is advised by the senior college that all of his courses will
transfer and he can complete the degree in 2 years.

In general, states have strongly promoted the concept of multiple entry
and exit points in health careers to minimize the loss of student time in
moving through certificate, associate, and baccalaureate programs. Without

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 199

strong mandates or incentives, however, such programs have difﬁculty
overcoming some inherent barriers. King discusses a number of them. For
example, curricular problems occur in judging the compatibility of didactic
and clinical program content, which makes it difﬁcult to assess advanced
placement. There is also, at times, a lack of communication between aca-
demic affairs and admissions ofﬁces to work out problems regarding credit
transfer policies. Finally, and perhaps most important, faculty professional
biases, in King’s view, “the most insidious barrier,” create an environment
of “undiscussable tension.” These biases label community college students
as “technically” trained and lacking in problem-solving experiences.

The committee recommends that alternative pathways to entry-level
practice be encouraged when feasible. State higher education coordinat-
ing authorities and legislative committees should insist on ﬂexibility in
educational mobility between community colleges and baccalaureate pro-
grams.

Role Congruence There is continuing tension between health care ad-
ministrators and professional groups over the tendency ofa ﬁeld to assume
more sophisticated or broader responsibilities and the perception of em-
ployers (or payers) as to the legitimate and valued functions that need to
be performed for patients.

Professional associations and program faculty see their responsibilities
as the deﬁning and shaping of their discipline. This process is reﬂected in
curriculum content and reinforced by accreditation. Health care admin-
istrators become concerned when they believe curriculum is being used as
a precursor to expanding the legal scope of practice and reimbursement
without recognition of what is possible or likely in practice. They also
become concerned when they believe that an occupation is at the same
time abandoning “hands-on” patient care for “professional” responsibilities
that are not valued highly by those outside the ﬁeld.

Care must be taken to ensure that students do not become mired in
these controversies. Ultimately, these issues are resolved by the market, as
shaped by consumer tastes and employer hiring practices, or by public
policy, as reﬂected in reimbursement or licensure decisions. While these
issues are being resolved, however, the committee believes that educators
have the responsibility to ensure that students have realistic expectations
of what their prospective occupation is like today—and not only what it
might be in the future.

The Agreement Between Education and S mices

Along with the education program’s responsibility to students is a re-
sponsibility to society to ensure that the health care system has the human

200 ALLIED HEALTH SERVICES

resources it needs to function well. Indeed, the rationale for the committee’s
support of public intervention in allied health supply issues is based on its
belief that the link between services and education needs to be strength-
ened.

In determining their program offerings, allied health educators are cau—
tioned by state higher education leaders and health care administrators to
avoid overtraining in both curriculum content and in length and level of
preparation. On the other side are the professions who caution against too
little training and who strive to elevate educational standards through li-
censure, program accreditation, and reimbursement standards.

The committee has heard arguments by the ﬁrst group that raising
educational qualiﬁcations is not only expensive to the student but to the
educational and health care systems as well, both of which are attempting
to control costs. Furthermore, proponents of this view contend that “ed—
ucation creep” exacerbates shortages by lengthening the time required to
prepare an individual for work. They also contend that there is little evi-
dence to suggest that current levels of education are creating care problems.

Counterarguments are most often based on the expanding knowledge
base that practitioners need to master and the limited time available in the
curriculum for such mastery. New sites of care, such as in the home or in
independent ofﬁce practice, require a level of judgment that can only be
achieved with increased education. Those concerned with an adequate
supply of practitioners point to the higher labor force participation rates
and longer tenure of those who have already attained the higher credential.

This committee encountered a number of these types of controversies
among the allied health fields. Some examples include physical therapists
attempting to establish the master’s degree as the entry-level standard, role
delineation debates among baccalaureate medical technologists and 2-year
medical laboratory technicians, proposals to limit the educational routes to
entry-level dietetics, and the movement of respiratory therapy to a bac-
calaureate entry-level standard. The case for promoting a single optimal
level of education is an exceedingly difﬁcult one to make on empirical
grounds. For example, when an IOM committee explored the controversy
over the three educational tracks leading to the registered nurse credential
(associate degree, diploma, and baccalaureate), it was unable to find con-
vincing evidence on the difference of performance among the graduates
(Institute of Medicine, 1983).

The committee neither endorses nor refutes the position of parties on
either side of these debates. In view of the lack of objective empirical
evidence and the limited scope of the present study, the committee could
. not justify offering conclusions that might inﬂuence the outcome of these
controversies. The committee does suggest, however, that those making

EDUCATIONAL POLICY’S ROLE IN INFLUENCING SUPPLY 201

decisions ensure that changing existing practice will not limit the supply
of practitioners nor make care excessively costly.

From the committee’s perspective the only sensible response to the mov-
ing targets of health care system change and the lack of certainty about
how to match education to future needs 15 a continuing feedback loop
between education and practice Graduate follow- -up studies that incor-
porate employer perceptions are the most direct measures of how well the
curriculum is preparing students. The aim of these studies, however, need
not be solely to tailor education to employer perceptions of need. Rather,
it should be the start of a dialogue. If students are not applying their
educational experiences fully, the problem may at times rest with the work
environment. A dialogue could potentially lead to a mutually beneﬁcial set
of activities involving more participation from health care managers in
curriculum design and greater involvement of educators in health services
research with practical application to clinical settings.

Various models are available for institutionalizing such interactions. In
some education programs, allied health education and services are jointly
administered by the same corporate entity. An example is Rush University
in Chicago where education and services are unified. Where this is not
feasible, the industry advisory boards common to many community colleges
can be used. Faculty practice plans or clinical afﬁliations may also be a
starting point to stimulate collaboration.

In those ﬁelds in which instrumentation plays a major role in job func-
tioning, industry/faculty collaboration provides a largely untapped re-
source. Manufacturers ultimately have a stake in human resources because
investments by health facilities in technological innovations may be seriously
jeopardized if there is a lack of adequately prepared personnel. Manufac-
turers should consider collaborating with educational institutions in creative
ways—for example, the use of equipment, faculty—industry research proj-
ects, short—term employment opportunities—as a means of ensuring an
appropriate human resource infrastructure to assist technology transfer.

Yet some stimulus is necessary to overcome the inertia of dealing with
these difﬁcult issues of collaboration. The committee sees a role both for
states and private foundations in providing that stimulus. State legislatures
should establish special bodies whose primary purpose would be to ad-
dress state and local issues in the education and employment of allied
health personnel. Private foundations should support university-based
centers for allied health studies and policy to provide a critical mass of
researchers and resources to advance technology assessment, health care
services research, and human resource utilization.

States have a major role in allied health education by virtue of their
support of public colleges and universities. In addition to this influence,

202 ALLIED HEALTH SERVICES

they are frequently drawn into debates over licensure issues that involve
changing scopes of practice and the licensing of new occupations. (These
regulatory issues are discussed in Chapter 7.)

Private foundations could have a major impact on the future of allied
health education and practice by creating centers of excellence in a few
academic institutions. Many advantages might be gained by coalescing a
core research faculty that also provides services. These mutually reenforc-
ing activities would enhance the quality of research and patient care. Fur-
thermore, these centers might then be a resource to other allied health
education programs regionally 0r nationally.

The committee believes that the interest of state legislatures and private
foundations in the endeavors we describe will be kindled and sustained
only by a continuing federal presence in the concerns of allied health
education and practice. For this reason, the committee makes the following
recommendation about the federal leadership: The Department of Health
and Human Services should maintain an organizational focal point on
allied health personnel to implement the grant programs recommended
in this report, to coordinate the recommended work of the interagency
data task force (recommended in Chapter 2), and to facilitate commu-
nication between state legislative committees and the federal government.

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6

The Health Care Employer’s
Perspective

 

MANY OF THE THEMES THAT RUN SEPARATELY through this report
come together when we begin to view allied health workers from the
perspective of health care employers. When the supply of practitioners in
an allied health field declines because fewer students choose that career or
because schools close, health care administrators who employ allied health
personnel are among the first to experience the change. If licensure laws
change or a new technology is introduced, employers are among the first
to respond to the change. When a glut of workers in an allied health field
exists in a locality, employers notice it in the number of responses they get
to vacancies they advertise.

Employers are not merely users of a given supply of allied health per-
sonnel, however—they are also active participants in the forces that de-
termine the supply of workers. In other words, the quantity of workers
demanded and the quantity supplied are not independent. Wage and salary
rates and working conditions affect the supply of workers. The supply of
workers in turn affects the wages, salaries, and working conditions that
they are offered. Yet employers setting wage and salary levels have to
balance many considerations other than the amount of money needed to
attract the required number of workers. They must consider the payment
they can get for services and the bottom-line impact of personnel expenses,
the regulatory requirements that constrain work force deployment, and
the skills and knowledge demanded by the technologies in use.

In the past, cost-based reimbursement, the absence of competition, and
a generally adequate supply of allied health personnel allowed adminis-
trators to make the salary adjustments that were needed to maintain their

206

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 207

desired stafﬁng levels. They were able to accomplish this without appre-
ciably changing stafﬁng or service levels or the deployment of staff. Yet
changes in the health care system and in allied health labor markets may
force administrators to rethink their stafﬁng practices. There will be in—
creasing competition for technically oriented workers, who have more em-
ployment options than nontechnical workers. In addition, administrators
will have strong economic incentives to control personnel costs to compete
in terms of price, yet remain ﬁnancially viable.

These changes have created a new environment with which administra-
tors have little experience. Although some administrators have had to face
periodic shortages of nurses, only recently have they faced personnel short-
ages and price competition simultaneously. There is no historical pattern
to indicate how employers will adapt to difﬁculties in hiring and stafﬁng.

The committee identiﬁed some allied health professions in which short-
ages are likely to occur if changes in the labor market fail to take place.
This chapter focuses on forestalling shortages; it emphasizes the impor-
tance of planning for the future. Market mechanisms will force adjustments
that will eventually decrease stresses in the allied health labor market. Yet
markets adjust slowly. For example, there is a considerable lag between
educational institutions recognizing and responding to increased student
interest in an allied health ﬁeld and an increased number of graduates in
that ﬁeld. Employers have many reasons to act early to forestall possible
personnel shortages. For instance, acute shortages of workers in an allied
health ﬁeld may cause salaries to rise sharply, some services to close, or
the initiation of new needed services to be postponed. More subtly, the
quality of health care may be eroded if, over extended periods of time,
too few existing employees must struggle to maintain services. These and
other serious service dislocations could be reduced if administrators were
to respond appropriately to early market signals.

In this chapter the committee focuses mainly on what personnel admin-
istrators, corporate human resource administrators, and department heads
in all types of health care facilities—hospitals, nursing homes, freestanding
facilities—might consider doing to help relieve or prevent personnel short-
ages. It discusses two types of activities that can produce gains in personnel
supply: (1) making employment more attractive, and (2) using the available
work force more effectively. None of the activities discussed is new; they
have been tried in ﬁelds other than allied health. There is a need for
further investigation, however, to ascertain which activities are best suited
to resolve problems with the allied health labor force, taking into account
the different characteristics of the work force in each ﬁeld.

There are other ways in which health care providers can lessen their
personnel problems. For instance, hospitals in Texas have responded to
shortages by using the state hospital association to mount an elaborate

208 ALLIED HEALTH SERVICES

campaign to recruit high school graduates into health careers (Texas Health
Careers, 1987). Other mechanisms, such as offering vacationing high school
students jobs in health care facilities, are also used to inform and encourage
students to select health care careers.

Throughout this chapter, terms such as “human resource administrators”
and “facility administrators” are used. These terms are purposefully vague.
Health care organizations often have a personnel function to facilitate the
details of personnel management, departmental administrators who make
decisions about the deployment of staff, and upper level human resource
administrators who deal with facility-wide labor force issues. This frag-
mentation makes it difﬁcult to develop and implement creative stafﬁng
arrangements that would likely be part of the solution to allied health
stafﬁng problems.

STRATEGIES FOR EMPLOYERS TO ENHANCE THE SUPPLY
OF ALLIED HEALTH PRACTITIONERS

Several factors play roles in creating imbalances between the supply of
and demand for allied health workers: the diminishing size of the college-
age population; students’ propensities to choose careers outside of health
care; and the decreasing availability of allied health programs on the one
hand and the aging of the population, disease patterns, and technological
advances in health care on the other These imbalances will likely remain
unless something changes on one or both sides of the equation. However,
generalizations of this sort do not apply to all allied health ﬁelds or to all
parts of the country. Demand and supply vary from place to place, and
with varying characteristic circumstances. Individual facilities and areas will
in some cases experience an adequate or even excess supply of personnel
in fields in which a national shortage is predicted, and the balance between
supply and demand will differ among the ﬁelds. This is readily apparent
today as facility administrators in some parts of the country struggle to
hire physical therapists when, for example, respiratory therapists are
plentiful.

The expectation is that in many parts of the nation and for many em—
ployers of allied health practitioners the labor market will be tight.

To increase the supply of workers, employers can intervene to make
education more accessible and employment more attractive. Students may
then be more likely to select allied health careers. People who have left the
work force to pursue other interests—raising families, new careers, or
leisure—may return. In addition, workers may choose to remain in the
work force longer or to remain in a particular career longer. Increasing
the supply of workers by encouraging greater numbers of students to enter
the allied health ﬁelds is a strategy that depends both on employers making

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 209

, employment in allied health careers more attractive and on educational
institutions expanding programs in response to increased student demand.

The second strategy for coping with shortages, using workers more
productively or effectively, in essence reduces the demand for allied health
personnel at a given level of output. Yet there are limits to the productivity
improvements that can be achieved. These limits can result from regulatory
restrictions, the skills of individuals, technological constraints, or the nature
of the work. The challenge for administrators in today’s competitive health
care environment is to try to ensure that productivity improvements are
pushed to their limits.

Undertaking one or both of these strategies would require a serious
reconsideration of the role of human resource management. For many
facility administrators, it would mean giving human resource management
a higher priority than in the past. Yet such investments or efforts would
be repaid if the service dislocations that could result from tight labor mar-
kets were avoided. Moreover, private sector employers must take the ini-
tiative in enhancing the supply of allied health personnel. The public policy
options, such as programs of grants or scholarships, cannot on their own
solve manpower problems. Making education inexpensive and readily avail-
able might attract some people into allied health fields, but unless good
jobs offering competitive wages are available, too few people will be at-
tracted, and those who choose an allied health occupation will not stay in
it long.

Salaries

In a perfectly competitive market, an imbalance between demand and ,
supply would cause prices to change until demand and supply were once
again in equilibrium. Thus, if a shortfall of allied health personnel were
to occur, wage rates would be expected to rise, demand would fall, and
the supply of personnel would increase to match demand. This series of
reactions is likely to occur in the allied health personnel market. Yet market
forces do not always work freely, and there can be delays before equilibrium
is reestablished. If demand increases at a greater rate than supply, wages
may rise, but there will be a lag before supply catches Up with demand. In
addition, wage rates may be slow to respond to supply shortages if em-
ployers are unwilling or unable to raise wages. An explanation offered for
the slow adjustment of nurses’ compensation is that large health care pro-
viders, such as hospitals, have often been one of just a few employers of
allied health practitioners in a locality. Realizing that these practitioners
have few alternative places at which to work, employers have been able to
keep wages down (Aiken, 1982). In many local markets, however, the
competition for allied health practitioners has been increasing with a pro-

210 ALLIED HEALTH SERVICES

liferation of work sites—freestanding units of numerous types, sometimes
independent practice options, and so on. Slow wage adjustments can be
expected if employers do not recognize that wage competition is taking
place. There are also many reasons why employers may be reluctant to
adjust wages.

Sometimes employers recognize that competition for workers is occur-
ring but are unable to compete with the salaries being offered by other
organizations. Some types of employers for whom this is likely to be true
are discussed at the end of this chapter. During the course of the study
the committee often heard of allied health practitioners who left traditional
employment settings to establish independent practices or to work for
employers paying substantially higher salaries—for example, health spas,
food manufacturers, and biotechnology ﬁrms. The committee also heard
that the traditional service ethic that in the past attracted individuals to
relatively low-paying health care jobs is being eroded. Opportunities in
alternative places of work or higher paying careers are felt to overwhelm
the traditional service satisfaction.

Employers’ reluctance to respond to indications of a personnel shortage
by raising salaries is due not only to the expense of paying higher wages
but also to the fact that the compensation levels of the many types of workers
in a hospital are interrelated. An increase in one group’s pay is likely to
be quickly followed by increases for other workers. Such failures of the
market are not unique to health care providers. The Wall Street journal
(Mitchell, 1987), noting a serious shortage of skilled blue-collar craftsmen,
remarked:

Surprisingly, the labor market has sparked only modest wage gains so far. Although
desperate for certain key skills, some employers would rather limp along without
a full workforce than raise wages high enough to attract needed workers . . . many
companies have chosen to ignore issues of supply and demand for fear that higher
labor costs will make it more difficult to compete.

A similar attitude prevails in health care. The New York Times (Uchitelle,
1987) cited Jerome Grossman, chairman of the New England Medical
Center, where 200 of 2,800 jobs were vacant, as saying “The amounts we
can charge patients are capped and so . . . we are forced to make trade-
offs.” Moreover, there are sometimes alternatives to pay increases. For
example, when laboratory technicians are in short supply, chemists and
individuals trained in other relevant disciplines can be substituted. When
there are alternative sources of workers, such as lower level practitioners
or individuals with other training, substitution may be a preferable alter-
native to raising pay. For example, in one locality in which there is an
oversupply of dentists and a shortage of hygienists, an HMO uses dentists
to perform the hygienists’ tasks. In some allied health ﬁelds, however, the
freedom to substitute personnel is constrained by regulation.

THE HEALTH CARE EMPLOYERS PERSPECTIVE 211

Alternatively, other ways of dealing with personnel shortages include
marginally curtailing services, asking allied health employees to work over-
time, or taking measures to increase output.

Other ways of attracting personnel through economic incentives without
increasing wages or salaries include paying bonuses for joining and staying
on staff, and offering continuing education and day-care subsidies. These
methods avoid an upward shift in pay scales; consequently, if utilization
or occupancy rates decline the employers are not left with an excessively
highly paid staff when the supply of workers is plentiful. Evidently, health
care administrators, who are necessarily concerned with their organization’s
bottom line, have an array of strategies available that can be implemented
before wage rates are increased. Thus, a lag in the response of wages to a
perceived shortage of personnel is not unexpected.

Although raising salaries has been shown to increase the size of the
nursing work force, other economic factors also influence the decision to
work. Family income is important. As spouses’ incomes rise, nurses tend
to reduce their working hours or to stop working altogether. In addition,
when nurses’ salaries become high enough, some nurses reduce the number
of hours they work. Conversely, in times of high unemployment, inactive
nurses often return to the work force (Aiken, 1982). These phenomena
are likely to occur in some of the allied health ﬁelds—in particular, those
that are mainly composed of women and that are similar to nursing in
education and pay levels.

An analysis of nurses’ compensation in relation to changes in the balance
of demand and supply notes that sometimes wage increases have lagged
behind shortages. The same analysis also notes that wage increases have
repeatedly succeeded in reducing shortages (Aiken and Mullinex, 1987).

Pay differentials between various educational levels in the same occu—
pation also have the potential of increasing or decreasing the supply of
personnel of a given level. For example, when there was no difference
between the earnings of baccalaureate nurses and associate degree nurses,
students realized that the economic return to the 2-year education was
higher than the return to the 4-year program, and the number of associate
degree graduates eventually exceeded the number of baccalaureate grad—
uates (Buerhaus, 1987).

Pay levels affect the supply of allied health practitioners at each point at
which an individual makes a career decision. Although economic consid-
erations often are not the sole or primary considerations, earnings potential
is one of many factors considered by students who are selecting an edu-
cational program. Once started on a career, satisfaction with current earn-
ing levels and expected increases in earnings will ﬁgure in decisions to
continue working; to leave the work force; to pursue child care, leisure,
or other unpaid activities; or to change to another occupation with better
compensation. Similarly, the return to an occupation will be in part de-

212 ALLIED HEALTH SERVICES

pendent on pay levels—especially when the cost of work includes major
expenditures such as child care.

How does allied health compensation compare with that in other oc—
cupations? First, compensation for allied health practitioners should be
understood in the context of women’s earnings, because women dominate
many allied health ﬁelds. In 1986 women earned on average 69.2 cents
for every dollar earned by men (Mellor, 1987). Moreover, occupations in
which women represent the majority of workers tend to rank lower in
terms of earnings than male-dominated occupations (Rytina, 1982). The
American Physical Therapy Association is one group that is trying to ad-
dress these problems. It recently examined factors contributing to the dis-
parity in professional and economic status between men and women members
as indicated by self-employment, administrative responsibility, graduate
degrees, and earnings. Full—time salaried female physical therapists had
annual salaries that were only 85 percent of those of full-time salaried men.
Self-employed physical therapists are more likely to be men (62 percent)
and they earn more than self-employed women physical therapists. The
annual gross earnings of these women were 71 percent of those of self-
employed men. The study concluded that the association should explore
approaches for creating career ladders, encourage women to commit them-
selves to their careers and to the maintenance of their skills, and consider
societal barriers that limit women’s aspirations and opportunities (Reagan,
1986).

Table 6-1 arrays compensation data for several allied health ﬁelds and
other selected occupations. These data for allied health occupations were
obtained through a national survey of 33 hospitals, 16 medical schools, and
28 medical centers. These institutions were chosen for their similarity in
size to the University of Texas Medical Branch at Galveston, which has
1,100 beds and 7,500 employees. Thirteen of the institutions are in Texas,
Arkansas, and Louisiana, which represents an oversampling of that region.
Thus, these data pertain to large institutions and have a regional bias. The
occupational categories are carefully deﬁned and clear, and although the
Texas-Arkansas-Louisiana region is oversampled there are no other rea-
sons to believe that the manpower markets of the institutions have any
special characteristics. In Table 6-1 the starting rate refers to the rate
normally paid to ﬁll a vacancy in the occupation. The maximum rate is
the highest rate actually paid to employees in the occupation (University
of Texas Medical Branch, 1986).

Data for the other occupations are from a nationwide salary survey of
ﬁrms with at least 50 employees. Each occupation was divided into levels
with detailed job content descriptions for each level. For the non-allied
health ﬁelds the starting salary in Table 6-1 is for the lowest level, and the
maximum is for the highest level (Bureau of Labor Statistics, 1986). Some

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 213

TABLE 6-1 Monthly Salary Ranges of Selected Allied Health
Occupations and Other Occupations, 1986

 

 

Mean Mean
Starting Maximum Percentage
Occupation Rate Rate Difference
Audiologist $1,872 $2,334 25
Dietitian 1,676 2,196 31
Electrocardiograph technician 1,073 1,332 24
Medical lab technician 1,222 1,622 33
Medical record administrator 2,076 2,637 27
Medical record technician 1,272 1,595 25
Medical technologist 1,630 2,174 33
Nuclear magnetic resonance technologist 1,596 2,033 27
Occupational therapist 1,777 2,219 25
Physical therapist 1,845 2,338 27
Radiologic technologist 1,435 1,900 32
Radiation therapy technologist 1,651 2,094 27
Respiratory therapist 1,481 1,855 25
Speech—language pathologist 1,857 2,318 25
Accountant 1,752 5,129 93
Accounting clerk 1,043 1,823 75
Attorney 2,584 8,431 226
Auditor 1,795 3,309 84
Buyer 1,770 3,442 94
Computer operator 1,144 2,416 111
Computer programmer 1,736 3,578 106
Drafter 1,088 2,584 137
Engineering technician 1,407 2,726 94
Engineer 2,322 6,585 183
File clerk 861 1,302 51
Secretary 1,361 2,338 72
Stenographer 1,531 1,812 18
Systems analyst 2,428 5,981 173
Typist 1,049 1,404 34

 

SOURCES: University of Texas Medical Branch (1986); Bureau of Labor Statistics
(1986),

of the occupations selected for inclusion in Table 6-1 were chosen because
they require investments in education comparable to those required in the
allied health ﬁelds. Others were chosen to show how compensation for a
lesser educational investment compares with compensation in allied health
occupations. The table indicates that starting salaries for allied health ﬁelds
in some cases do not compare unfavorably with other occupations requiring
similar educational investments or that students might consider as alter-
native careers. For example, auditors and accountants must have bachelor’s

214 ALLIED HEALTH SERVICES

degrees and receive mean monthly starting salaries of $1,797 and $1,752,
respectively; these are similar to or a little below the mean starting salaries
for physical and occupational therapists and medical record administrators,
occupations that also require bachelor’s degrees. In computer ﬁelds the
starting salaries of systems analysts exceed the starting salaries for speech—
language pathologists and audiologists for whom a master’s degree is the
entry level requirement. Engineering technicians, who are described as
“semiprofessional,” and computer operators are included in technical sup-
port operations and can be considered equivalent to medical laboratory
and medical record technicians with associate degrees. Engineering tech-
nicians start at salaries roughly $150 per month higher than the equivalent
allied health ﬁelds; computer operators start at roughly $100 per month
lower. It will come as no surprise that attorneys and engineers start at
salaries closer to the mean maximum rate than to the starting salary for
speech—language pathologists and audiologists.

Increases in earnings over the length of a career are substantially lower
in allied health fields than in the other listed occupations. The salary spread
for each of the non- a—llied health ﬁelds listed, except typists, is larger than
that in any allied health ﬁeld.

In sum, these data indicate that although allied health practitioners’
starting pay is not always competitive with the earnings of workers in
alternative ﬁelds, the differences are not large. However, the relative lack
of a pay ladder puts individuals who stay in allied health ﬁelds at a signif-
icant economic disadvantage. Although there is no empirical evidence that
prospective students turn away from allied health careers because of wage
compression, it seems likely that students know of it and react by seeking
careers with brighter economic futures.

An important factor for employers who are considering raising pay to
alleviate personnel shortages is the value of the job to the institution. This
factor is brought out starkly when administrators consider the costs and
beneﬁts of expanding the pay ladder—in other words, paying more for
experience. In some facilities, and for some allied health fields, experience
may be of little value from the employer’s perspective. Indeed, recent
graduates may be preferable if they bring more up-to—date skills or the
enthusiasm of a novice to the job. Why then should an organization reward
experience? One answer is the high cost of recruiting and orienting new
personnel. In addition, some would say that treating employees like dis-
posable objects by not recognizing loyalty or tenure is simply inhumane
management. Furthermore, by combining further education with pay and
career progression, the quality of services may be upgraded and advances
in knowledge can be incorporated into the facility’s practice. This latter
point becomes more important when the stream of newly trained practi—

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 215

tioners slows. Employers who must substantially increase pay to attract
needed personnel may consider examining job content and restricting tasks
to ensure that the now more expensive personnel are used effectively. If
higher compensation succeeds in increasing by even a small amount the
time that individuals remain in the allied health work force (either by
continuing to work or by returning to work), the impact on supply can be
signiﬁcant.

Although supply problems may be alleviated by increasing compensation,
employers may be reluctant to act. The most fundamental and obvious
reason for this reluctance has to do with the facility’s bottom line. Higher
salaries may not appear justiﬁed by the revenue generated for a service.
Another possible deterrent for some managers is that pay raises in one
occupation may produce similar salary expectations in other hospital oc-
cupations.

In the face of price competition and prospective payment, hospital ﬁ-
nancial administrators feel they have reason to be reluctant to increase
salary expenses. At a recent Senate Finance Subcommittee hearing, a
spokesman for the American Hospital Association said that the level of
Medicare payments constrained hospitals’ revenues so that nurses’ salaries
could not be increased (Health Professions Report, 1987). Yet data indicate
that the early 19805 were relatively proﬁtable for hospitals. Hospital op-
erating margins—key indicators of their ﬁscal health—peaked in 1984
(Table 6-2). By September 1987 total operating margins and patient rev—
enue operating margins in community hospitals were close to the levels of
the early 19805, and there were no signs that the deterioration in ﬁnancial
status had ceased. However, operating margins in the 19605 and 19705
were consistently lower than in the 19805. Thus, although some hospitals
are running in the red and the situation for the average hospital has
deteriorated in the past few years, hospital administrators with longer mem-
ories may not be feeling so pressured that they will not consider salary
1ncreases.

Furthermore, a hospital’s ﬁnancial viability rests to a great extent on its
ability to admit and care for patients. If a lack of staff in any allied health
ﬁeld interferes with this ability or slows down discharge rates, then a wage
increase is likely to be more than offset by revenue increases or decreases
in other costs that result from the return to normal services.

Indeed, employers who need scarce allied health employees may have
no choice but to raise wages. As one observer put it,

Gone are the days when doctors and hospitals could look upon America’s bright
and motivated women as a source of cheap labor denied economic opportunities
elsewhere. To attract this pool of talented workers into health care, we must get
used to the notion of paying competitive wages. (Reinhardt, 1987)

216 ALLIED HEALTH SERVICES

TABLE 6-2 Operating Margins (percentage) for
US. Community Hospitals, 1963—1987

Operating Margin

 

 

 

Year Total Revenue Patient Revenue
1963 2.5 — 6.0
1965 2.3 — 5.1
1967 2.6 —4.6
1969 2.4 — 3.9
1971 2.3 —3.2
1973 1.2 —4.4
1975 2.3 — 3.0
1977 3.5 —0.6
1979 3.9 —0.6
1981 4.7 0.2
1983 5.1 1.0
1985 5.2 1.5
198711 4.8 0.3

 

”january through November.

SOURCE: American Hospital Association, Hospital Data Center
(1988).

Other Strategies to Increase Job and
Occupational Tenure

A review of the recent periodical literature of hospital administration reveals scant
coverage of human resource management. Most of that attention is focused on
short-term issues in spite of radical and long-term changes in the hospital’s envi-
ronment as the nation redeﬁnes how health care is perceived, delivered and paid
for. (Mansﬁeld, 1987)

So opens the report of a literature review of the nine major hospital
administration and personnel journals for the years 1983 through 1985,
forcing the conclusion that human resource management is not a high
priority for health services researchers or for their audience of health care
corporate executives and hospital administrators. This is a surprising ﬁnd-
ing when we consider that payroll represents about half of hospital ex-
penses. The review also noted that, of 157 articles related to human resources,
71 percent were published in Nursing Management. The committee’s own
search of the Cumulative Index of Nursing and Allied Health Literature
(which covers nursing and allied health personnel) and of selected psy-
chological, management, and popular publications was similarly revealing.
Searching literature published since 1983 on such descriptors as the oc-
cupational titles of each of the 10 allied health ﬁelds covered in this report,
as well as “manpower, turnover,” “retention,” and “personnel,” 36 articles
were found. Thirty related to nursing.

” u

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 217

Human resource administrators are often in a perplexing situation. They
manage a resource that is fundamental to ensuring the quantity and quality
of care desired by management and whose cost accounts for a major portion
of the facility’s expenditures. Yet, as the committee heard at one of its
workshops, during site visits, and through discussions with knowledgeable
observers, human resource managers are not often given the visibility or
status they need to do their complex job. Moreover, even large health care
corporations have not generally changed the way they manage human
resources as they adapt to the changing health care environment.

Human resource administrators are most often expected to respond to
and implement the decisions of strategic planners. Yet strategic planners
do not always recognize the constraints and changes in labor markets that
confront human resource administrators. If, however, strategic manage-
ment and human resource management were brought together, several
beneﬁts could ensue. The importance of human resource management as
a vital part of facility management would be conﬁrmed. Plans would be
made with cognizance of labor market conditions, and human resource
administrators would be in a position to act early to implement plans in
whose development they had participated.

However, more often, personnel administrators must assemble a labor
force to provide services decided on by other administrators. Experience
shows that it is not until labor markets become tight that upper management
supports serious efforts to retain and attract allied health practitioners.

The previous section suggested that pay increases would enhance the
supply of allied health personnel. But money, although important, is only
one of the many factors that make employment in a field an attractive
alternative to leisure, home activities, or other types of employment. What
makes employment attractive? What nonmonetary aspects of a job produce
satisfaction or dissatisfaction? The knowledge base for answering these
questions about the allied health fields is sparse. A review of the general
job satisfaction literature notes that explanations of differences in satisfac-
tion are usually related either to individual characteristics of workers, in—
cluding their needs and values, or to the nature of the jobs and the
characteristics of employing organizations (Hanson et al., 1987).

Employers should not assume that factors they cannot control, such as
family responsibilities, dominate employee decisions. A review of studies
of self—reported reasons for resignation of nurses notes that at least one-
third of the resignations resulted from job dissatisfaction, and a recent
study attributed three—quarters of “contemplated turnover” to job problems
(Weisman et al., 1981).

Workers’ job requirements are known to vary according to sex, race, age,
and so on. The Hudson Institute in its project “Workforce 2000” drew
some conclusions about work force problems that employers will have to

218 ALLIED HEALTH SERVICES

address if they want to hire the workers of the future. With the increasing
age of the work force, they must be concerned about the adaptability of
these workers and their willingness to learn. With regard to working women,
reform is needed in day care, time off (time off for child care, sick leave,
flexible hours, etc.), and policies to assist welfare mothers in entering the
labor force. The full utilization of the work force will require integrating
blacks and Hispanics into the labor market, but that means overcoming
the fact that they are also the least advantaged groups in our society with
respect to skill levels and educational backgrounds (Hudson Institute, 1987).
Employers using an allied health work force that is largely composed of
women will want to pay attention to findings about what makes a job
appealing to women. Some results suggest that women’s unique work needs
stem from their dual responsibilities at home and at work. Studies indicate
that factors such as travel time to and from work are more important to
women than to men. For those women who are not career motivated and
who are more interested in supplementing the household income or getting
out of the house, jobs that substitute other rewards for advancement, sta-
bility, and high pay may have attractions (Hanson et al., 1987). Some
differences in work force behavior between men and women include women
being less likely to remain in one occupation and one particular job than
men, and women having more frequent career interruptions—although
this latter difference may be diminishing. Women who pursue longer term
careers are less likely to differ from men in the factors that contribute to
job satisfaction.

For many workers, satisfaction, dissatisfaction, and decisions to leave or
stay in a job or ﬁeld are based on factors related to their job tasks, how
they ﬁt into the organizational structure, and expectations about their work-
ing conditions. The nursing literature is replete with analyses of reasons
for dissatisfaction—boredom, limited possibilities for advancement, lack of
status, lack of opportunities for full use of their skills, lack of further
educational opportunities, lack of autonomy, problems in relationships with
physicians, and stafﬁng patterns that do not allow for the provision of high
quality care. (See, for example, Price and Mueller, 1981; Weisman et al.,
1981 and a literature review that notes that every major study since the
19605 has pointed to the factors of autonomy, interpersonal relations, and
job status as critical components of job satisfaction, Institute of Medicine,
1983). Satisfaction often stems from recognition by peers and supervisors,
professional growth, perceptions of being important to patient care and to
the institution, and involvement in decisions concerning both patient care
and institutional policy. An analysis of the importance of these factors in
determining turnover found that autonomy is the strongest predictor of
job satisfaction, and the supervisor’s responsiveness to the nurse’s work

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 219

and communication needs is the best predictor of a sense of autonomy
(Weisman et al., 1981).

Findings of this sort have generated numerous strategies (not always
adopted) to enrich nurses’ working environments in order to extend both
job and occupational tenure. Strategies include creating decision—making
links among the chief executive ofﬁcer, nursing service administrator, and
staff nurses; introducing primary nursing; and developing patterns of up-
ward mobility. One important difference between nursing and allied health
in this regard is that although allied health practitioners hold administrative
jobs—managing laboratories, dietary services, radiology departments, and
so on—-there is usually no umbrella allied health administrator position to
promote the interests and raise the level of visibility of the allied health
work force. By way of contrast, hospitals commonly have a director or vice-
president for nursing, who increasingly is assuming even broader respon-
sibilities such as vice-president for patient services, which sometimes sub-
sumes allied health services. The fragmented, diverse nature of allied health
makes the development of a uniﬁed power block within institutions difﬁ-
cult. Consequently, these ﬁelds have found it difﬁcult to establish the link-
ages to central administration that have been helpful in addressing work
environment issues for nurses.

The nurse—physician relationship is an important factor in the way nurses
perceive their roles and in their job satisfaction. For many allied health
occupations, physicians also play a major role in shaping an environment
that will induce practitioners to extend their tenure. Reporting on a suc-
cessful effort to lengthen nurses’ tenure, one nursing administrator noted:

The physician’s role in nurse retention cannot be overstated. When there is close
communication between physicians and nurses, an increased level of satisfaction
for both parties is evident. Nothing enhances the role of the nurse as much as
awareness that a physician is hearing her perspective of a patient care issue. Or-
thopedic physicians and orthopedic nurses simultaneously requested that nursing
practice be expanded to include more activities. Nursing activities then were planned
and implemented as a joint venture. (Araujo, 1980)

Reports like these underline the importance of action by facility adminis-
trators to encourage physicians to be involved in efforts to extend tenure.

Also of importance is the role of research. Knowledge of the factors that
persuade practitioners to leave or remain in their allied health ﬁeld could
be usefully expanded—and what seems obvious is not always the right
answer. For example, a small study of burnout among respiratory care
personnel (Shelledy and Mikles, 1987) found, to the authors’ surprise, that
hours worked per shift or per week, shift assignment, frequency of rotation
of daily work assignments, variety of procedures performed, and number

220 ALLIED HEALTH SERVICES

of treatments per shift did not relate to burnout. Lower burnout rates were
found in practitioners with higher educational levels, a greater sense of
autonomy, and perceptions that high-quality work was being done in their
departments.

Just as with salary decisions, however, it is unreasonable to expect facility
administrators to make changes that are not in their institutions’ best in-
terests. Although opportunities for upward mobility are generally seen as
an important element of job satisfaction, there are clearly limits to the
number of higher level practitioners that are needed. In some cases, any
sort of upward mobility may be impracticable. As an alternative, employers
may find that encouraging an expansion of skills to another area can sustain
employee interest and extend tenure in work that could become tedious.
Methodist Hospital in Indianapolis, Indiana, sponsors a program called
“Add—A-Comp” that enables individuals with health care experience to
acquire additional competencies. The program also fulﬁlls employers’ needs
for cross-trained personnel. Moreover, employees who are more challenged
and stimulated are less likely to leave an employer or the work force.

A secondary benefit of improving job satisfaction will accrue to employers
interested in avoiding unionization among their employees. Health care
union membership, which has been growing despite a national decline in
other union membership, stands at about 20 percent. Recent organizing
issues have included quality of care, quality of work, stress, job restructur-
ing, and beneﬁts. Because of similar concerns with issues of compensation,
job security, and meaningful work involvement, professionals and white-
collar workers are identifying with blue-collar workers and with unionized
groups (American Hospital Association, Department of Human Resources,
1986). Thus, health care employers cannot rely on their employees’ sense
of professional status to avoid unionization. By making adaptations to in-
crease job satisfaction, however, employers can attend to issues that might
otherwise result in union activity.

Lower level health care practitioners such as orderlies and technicians
have negotiated contracts that include retraining programs in case of layoff.
As a result, one hospital has started training programs for sterilization
technicians and licensed practical nurses (Lunzer, 1987). Organizations with
contracts like these have a ready pool of workers whose training can be
channeled toward skills needed by the facility. Thus, although unionization
can reduce an employer’s ability to redesign jobs and may reduce work
force ﬂexibility, it can also occasionally increase the options’available in
uses of manpower.

job satisfaction also relates to the socialization process that occurs during
professional education and through contact with role models. This social-
ization emphasizes the importance of upward mobility. Studies of nursing
indicate that higher levels of education correlate with a greater likelihood

THE HEALTH CARE EMPLOYERS PERSPECTIVE 221

of job dissatisfaction (Weisman et al., 1981). Although this correlation could
be related to frustrations that occur if practitioners do not fully use their
skills, the job dissatisfaction research ﬁndings relating to upward mobility,
role, use of skills, and autonomy all point to the conclusion that some
discrepancy exists between what employers need and the aspirations and
needs of graduates from educational programs. More extensive commu-
nication among educators, employers, and professional associations might
help to improve the ﬁt between the needs of employers and those of their
employees, and thus might also help extend job and occupational tenure.

The problem of matching education with workplace needs is also ad—
dressed in Chapter 5, in which educational issues are discussed. That chap-
ter contains a recommendation that the groups most influential in developing
work site tasks, curricula, and aspirations—educators, employers, and
professional associations—should interact more. One special problem they
might address is to attempt to ensure that the diversity of employers’ needs
is matched by a similar diversity in the education of practitioners. Allied
health jobs exist in numerous settings—hospitals, nursing homes, primary
care practices, and so on. Different settings vary in their need for various
ranges of skills and levels of expertise, even in a single ﬁeld. Reﬂecting this
diversity in the content and level of educational programs would help
increase job and occupational tenure by matching practitioners’ abilities
and aspirations with patient and institutional needs.

Another issue that could usefully be addressed by employers, profes—
sional associations, and educators also relates to professional aspirations.
Allied health practitioners working in health care facilities of all types
become part of a larger group of workers with an organizational structure.
The “medical model” of autonomous work, which is pursued by the many
physical therapists, speech—language pathologists, and laboratory technol-
ogists who become independent consultants, is not always either realistic
or attainable in complex medical settings or for most practitioners. These
practitioners need goals that provide satisfactory alternatives to indepen-
dent practice.

A further element, already noted in Chapter 5, is the provision of clinical
sites for education. The number of health care facilities providing sites for
the clinical component of educational programs is decreasing. Employers
should consider that the cost of providing clinical education is often offset
in the long run by an increased supply of practitioners and the avoidance
of personnel shortages.

ENHANCING THE USE OF THE EXISTING WORK FORCE

Easing scarcities in the supply of allied health practitioners by expanding
educational capacity is a strategy that only begins to be effective several

222 ALLIED HEALTH SERVICES

years after initiation. Of more immediate effect would be extending the
tenure of existing workers and bringing back into the work force individuals
who have chosen to leave it. A still different approach is to examine ways
of using the existing work force more productively and effectively.

In the early part of this chapter, it was noted that when demand for
allied health practitioners exceeds supply, market forces will drive up the
wages and salaries employers must pay to hire the needed personnel. This
increased compensation will, in the long run, enlarge the supply of workers.
It will also diminish the upward thrust of demand as employers, with a
more expensive work force, seek ways to contain this expense. An approach
that has the potential to provide a dual beneﬁt—increasing job satisfaction
as well as using staff more efﬁciently—is the restructuring of tasks and
staff deployment. This approach requires that administrators shed tradi—
tional ways of thinking about individual and departmental responsibilities
and allow themselves to consider new staff and task conﬁgurations. Some-
times expanded roles for lower level staff will permit more ﬂexible stafﬁng
of units, to the extent that regulation allows. Occasionally it is possible to
combine tasks to form a new, enlarged work module. Using multidiscipli-
nary teams can break down departmental barriers to permit enlarged spheres
of responsibility for individual staff. Many new conﬁgurations of tasks and
staff are possible, but they must be preceded by an investment in human
resource management to engage in the necessary fundamental analyses
and rethinking of tasks.

A familiar industrial response to manpower shortages or to perceptions
of overly high personnel expenses is attempts to improve labor productivity.
However, there is a common perception that the service sector of the
economy has very low rates of productivity growth (Kutcher and Mark,
1983) and that health care, because it requires a hands-on, one-on-one
approach, is not amenable to measures to increase productivity. Certainly,
if operating margins continue to deteriorate, it seems reasonable to expect
administrators to seek ways of improving productivity. If health care is
viewed not as a whole but rather as individual specific services, some areas
appear to have some potential for productivity gain. One of the areas often
cited is automation in medical laboratories.

Today’s ﬁnancial incentives to reduce costs are expected to encourage
the development and adoption of technologies that improve productivity.
Some structural changes in the way health care is delivered also have a
potential for productivity improvement. For instance, large-scale specialized
delivery sites (e.g., special surgery or imaging units) may be able to reap
economies of scale in the use of personnel. However, it is unlikely that
changes such as these will outweigh other changes—for example, the move
to home services and new, complex technologies—that use manpower in
a less productive manner.

THE HEALTH CARE EMPLOYER ’S PERSPECTIVE 223

The advantages and disadvantages of cross-trained or multicompetent
allied health personnel have been discussed for many years. In the past
the context was their use in solving rural health care stafﬁng problems.
Today, they are seen by some as innovative solutions to personnel shortages,
especially in small hospitals, physicians’ ofﬁces, and other small delivery
units. Multicompetent personnel are also regarded by some larger hospitals
as economical sources of staff who must be available 24 hours a day but
whose work time is punctuated by low-use periods. More generally, as
revenue restrictions force administrators to examine ways to control labor
expenses, employers are becoming interested in increasing labor produc-
tivity by decreasing specialization, as evidenced by the American Hospital
Association’s sponsorship of a number of workshops on the multiskilled
concept. A 1986 national survey of medical laboratory managers indicated
that 46.3 percent said they could use cross—trained personnel (Watrous,
1987). A survey of hospital administrators, directors of nursing, directors
of community health organizations, and physicians in Philadelphia showed
that multicompetent practitioners were already employed in approximately
a quarter of the hospitals. Sixty percent of the hospital administrators
surveyed said they were willing to employ multicompetent practitioners
now (Low and Weisbord, 1987), and educators report that their multicom-
petent graduates generally ﬁnd jobs that use their training (Blayney, 1982).
Using multicompetent practitioners is not an all—purpose solution, but it is
the result of an effort to think through the tasks that must be performed
and how the educational system can respond to, help meet the need.

Productivity improvements, however they are achieved, are deﬁned as
decreasing the input per unit of output. Thus, we say that productivity is
increased if a laboratory worker, for example, increases the number of
tests he or she performs per hour. Another way of thinking about how
best to use allied health manpower and thus improve productivity is to
redeﬁne output in terms of a contribution to patient care. To make this
deﬁnition operational, we must evaluate effectiveness. Output can be in-
creased, and pressures on manpower supply relieved, by reducing services
that do not contribute to patient welfare.

Suggestions of unnecessary care (or at least a lack of agreement about
what is appropriate care) are found in studies that show variations in the
amounts of service performed in different countries, in different regions
of the same country, and in different types of organizations. But infor-
mation about the identiﬁcation of effective and ineffective care by allied
health practitioners is not plentiful. Shroeder (1987) reports on studies that
have detected patterns of overuse. Overused procedures or technologies,
according to these studies, include white blood cell differential counts,
measurements of serum lactic dehydrogenase, blood cross matches, barium
enema studies, upper gastrointestinal series, nursing service orders, ton—

224 ALLIED HEALTH SERVICES

sillectomies, chest x rays, prescription drugs, preoperative screening tests,
and thyroid function tests. Shroeder adds:

A recent study from our institution estimated the proportion of redundancy among
a wide variety of diagnostic and nursing services for patients on a general medical
ward. Of the more than 8,000 services ordered for 173 patients during the obser—
vation period, 21% were judged to be unnecessary by faculty auditors who reviewed
the medical records. The most overused services were partial thromboplastin time
(deemed unnecessary in 63% of uses), stat/emergency orders (43%), nuclear med-
icine studies (26%) and platelet counts (25%).

Another way of assessing overutilization is by determining whether clinical services
contribute to patient management. Reports from several teaching institutions and
one community hospital show that as few as 3% t0 5% ofdiagnostic tests are actually
used in the management of the patients for whom they are ordered. (Shroeder,

1987)

Probably the allied health service most studied for overutilization is the
clinical laboratory. Barr (1987) suggests that ensuring effectiveness is in
part the responsibility of laboratory scientists, who should ask a number
of questions such as “Are the ordered tests appropriate for the patient’s
clinical condition?” “What level of accuracy and precision is needed for
clinical judgment?” Other investigators are working to develop methods
for detecting overutilization (see, for example, Eisenberg, 1982; Garg et
al., 1985).

Many questions about effectiveness remain unanswered. If cost-contain—
ment pressures continue to mount, some employing organizations may
initiate their own research. HMOs may shift their focus from a concentra-
tion on reducing hospitalization to reducing ineffective care in other areas.
Other prospectively paid providers also have reason to try to eliminate
excess services.

Finally, some allied health practitioners may want to undertake effec-
tiveness research to justify their place in patient care. Until such research
is done, they may be vulnerable to cuts by institutions seeking to reduce
personnel expenses.

EMPLOYERS WITH SPECIAL PROBLEMS

Some health care providers are particularly disadvantaged in the com-
petition for allied health practitioners. These employers will ﬁnd that, for
one reason or another, they cannot implement many of the strategies
discussed previously in this chapter. In this section the committee discusses
the predicaments of two of these employers—rural health care facilities
and nursing homes and other long-term care sites. The committee also
suggests some strategies they might ﬁnd useful in trying to cope with their
needs for allied health manpower.

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 225

Rural Health Care Facilities

According to the Census Bureau, more than a quarter of the population
of the United States lives in rural areas. These areas differ from other
parts of the nation in many aspects, and often these differences have
implications for the delivery of health care.

Rural areas are more sparsely populated than urban localities, and there—
fore fewer people live in the catchment area of a rural health care provider.
In addition, rural populations are more often poor (14 percent below the
poverty level, compared with 11 percent in metropolitan areas in 1981)
and elderly (13 percent over 65 compared with 10.7 percent in 1980);
therefore, they have different health statuses and health care needs. Ex-
amples of rural health status differences include higher infant mortality
rates; a higher incidence of hypertension, coronary heart disease, emphy-
sema, and some other chronic conditions; but a lower incidence of acute
conditions on the whole (Cordes and Wright, 1985).

Some of these differences may be related to differences in the health
care services available to rural populations. The hospital-bed-to-population
ratio is approximately the same for rural and nonrural areas, thanks to the
hospital construction program mandated by the Hill Burton Act of 1946.
Yet the number of health professionals in relation to total population is
less in rural areas, and the range of services offered by hospitals is narrower
(Cordes and Wright, 1985).

That rural hospitals have special problems is well documented. Of the
5,732 community hospitals in the United States in 1986, 47 percent were
rural and 17 percent had fewer than 50 beds. Eighty percent of the small
hospitals in the United States are rural. Small hospitals anywhere are more
likely to close than larger hospitals: of the 214 community hospitals that
closed between 1980 and 1985, 75 percent had fewer than 50 beds, 86
were rural, and 128 were urban (Health Resources and Services Admin-
istration, Ofﬁce of the Administrator, 1987).

The reasons for the vulnerability of rural hospitals may relate not only
to their rural characteristics but also to their small size. Analyses of Amer-
ican Hospital Association data (Table 6-3) show that, between 1980 and
1986, the smaller the hospital, the greater the deterioration in several key
indicators of strength. Operating margins, admissions, and occupancy rates
have fallen more and are lower in smaller hospitals. These data show why
raising salaries to attract allied health practitioners is not feasible for many
small rural hospitals.

It is more difﬁcult to attract practitioners to rural employment than to
other settings. Table 6-4 contrasts the ratio of practitioners to population
in metropolitan and nonmetropolitan settings for some allied health profes-
sions. It is evident that metropolitan areas in 1980 had a more plentiful

226

ALLIED HEALTH SERVICES

TABLE 6-3 Selected Indicators of Hospital Strength

 

 

Percentage Actual
Change, Percentage,
Indicator 1980—1986 1986
Operating margin
All hospitals 1.0 5.4
Hospitals with 25—49 beds —4.8 1.5
Hospitals with less than 25 beds —4.5 ~63
Admissions
A11 hospitals — 8.0
Hospitals with 25—49 beds — 39.8
Hospitals with less than 25 beds —44.8
Occupancy
All hospitals — 16.1 63.2
Hospitals with 25—49 beds —36.7 33.2
Hospitals with less than 25 beds — 31.7 27.4

 

SOURCE: Health Resources and Service Administration, Ofﬁce of the Administrator
(1987).

supply of practitioners in all the listed ﬁelds. The lower rural concentration
may be due in part to the lower concentration in rural areas of some of
the individuals and organizations that usually employ allied health prac-
titioners—dentists, physicians, and so on. But with the hospital-*bed-to-
population ratio quite similar in rural and nonrural areas, the usual em-
ployers of the majority of allied health practitioners would seem to be
present.

For rural hospitals, allied health employment problems can be Viewed

TABLE 6-4 Geographic Distribution of Selected Allied Health
Professions, 1980

 

 

Nonmetro
Number per 100,000 Ratio as
M—h Percentage of
Allied Health Profession Nonmetro Metro Metro Ratio
Dietitian 26.0 30.9 84
Speech therapist 14.4 19.5 74
Health aide (except nursing) 99.9 138.5 72
Inhalation therapist 16.6 23.1 72
Dental assistant 53.2 75.2 71
Health record technician 5.0 7.2 69
Radiologic technician 31.0 46.3 67
Physical therapist 12.7 21.1 60
Clinical laboratory technician 68.9 120.5 57
Dental hygienist 12.3 23.1 53
Occupational therapist 3.5 9.3 38

 

SOURCE: Hamburg (1985).

THE HEALTH CARE EMPLOYER ’s PERSPECTIVE 227

in three ways: (1) the difﬁculty of attracting practitioners to rural employ-
ment, (2) being able to afford the practitioners, and (3) ﬁnding practitioners
with the type of education and training that suits them for rural employ-
ment.

The geographic maldistribution of personnel in some health care fields
has been well studied. Less work has focused on the maldistribution of
allied health practitioners. Some lessons can be drawn from what is known
about other types of health care practitioners. Allied health education, like
most health care education, takes place primarily in metropolitan areas.
Most often, clinical experience is provided in acute care settings with suf-
ﬁcient patient volumes to support state-of-the-art, high-technology services.
Graduates are subsequently drawn to employment in similar settings for
several reasons. They perceive these settings as offering high-quality care,
personal challenges, full use of their education, and the stimulation of
contact with peers and supervisors. By contrast, to city-reared workers,
rural facilities are an unknown setting, often perceived as isolated, tech-
nologically backward, and with little room for advancement in their ﬁeld.
One lesson from studies of health personnel education and employment
decisions is that graduates who grew up in rural areas or whose education
included experience in these areas are more likely to choose rural em—
ployment.

Individuals whose roots are in rural areas can ﬁnd the monetary and
psychological costs of attending educational programs in metropolitan areas
prohibitive. Taking education to rural areas would help bring these indi-
viduals into the allied health work force. Such techniques include the use
of telecommunications technologies and “circuit riding” faculty. Employers
could assist such efforts by encouraging qualified allied health staff to
participate in teaching. They could also provide classroom space and clinical
experience in their facilities.

The employer’s role in increasing the supply of graduates who are fa-
miliar with rural settings is thus twofold: ﬁrst, to work with local high
schools and career counsellors to encourage students to pursue allied health
careers and second, to work with allied health educators to provide clinical
experience in their facilities. In Alabama a group of junior colleges and
the University of Alabama formed a consortium in 1969 to enhance the
supply of allied health practitioners in underserved areas. As described by
Keith Blayney (1981), dean of the School of Community and Allied Health
at the University of Alabama:

In 1969, the state’s junior college presidents and representatives of the University
of Alabama in Birmingham (UAB) met and endorsed the concept of a consortium
to link the two-year schools with UAB. The beneﬁts were readily apparent—by
sharing students with the Regional Technical Institute (RTI) at UAB, the dupli-
cation of speciﬁc allied health programs and their high costs could be avoided.
Also, students could attend school near their homes for the ﬁrst year of the program.

228 ALLIED HEALTH SERVICES

After the second year at RTI, graduates were likely to return to their homes, located
in the medically underserved areas of the state, and provide ancillary support for
medical services there. As the program developed, efforts were made to establish
clinical training sites for the students in or near their homes, thus providing an
additional impetus to return home.

Before their year of technical training at the RTI ends, the students spend six to
eight weeks in on-site clinical training. Although the RTI is located in the heart of
UAB’s Medical Center, where there is a large volume and variety of clinical ma-
terials, it soon became clear that the Medical Center alone would not be sufficient
to provide adequate experience for all the allied health students. As a result, linkage
students can now complete the last weeks of their clinical training at smaller health
care facilities throughout the state. These facilities range from doctors’ ofﬁces to
nursing homes, clinics, and hospitals. This arrangement has other advantages. The
students can work close to their homes, in facilities similar in 'size and scope to
those in which they will probably work. Also, upon graduation, the students are
often offered positions at the facilities where they did their training.

Since the number of clinical facilities has been expanded, a higher percentage of
RTI graudates have returned to rural areas to work. In 1977, 59% of graduates
of programs that have clinical training sites outside of Birmingham took jobs outside
of the city, while only 34% of the graduates who had no clinical affiliation outside
Birmingham left the city.

An evaluation of the linkage program after 11 years found that 66
percent of the graduates who remained in allied health fields returned to
their home counties to work (Cooper, 1982). Clearly, this model requires
serious commitments by employers and leaders in educational institutions
who are concerned with and willing to help resolve some of the problems
of rural care.

Another type of linkage would be for rural employers to arrange regular,
periodic secondment to an urban facility for their allied health employees.
Arrangements with educational programs and leaders in allied health ﬁelds
to provide lectures or seminars to practitioners in rural areas might also
help dispel fears of isolation and ensure that practitioners are kept up to
date in their ﬁeld—generous allowances for continuing education would
also help to achieve this goal.

Rural employers who operate low-volume facilities that cannot afford or
fully use a full-time staff member can also try to develop linkages. In
Wisconsin, 22 small rural hospitals have formed a cooperative that shares
services, mobile technologies, and professional staff who travel among the
hospitals (Health Resources and Services Administration, Ofﬁce of the
Administrator, 1987). Employer—initiated sharing (as opposed to employees
who on their own ﬁnd several part-time jobs) may also appeal to practi-
tioners because they get full-time employment and benefits that are often
not offered to part-time employees.

THE HEALTH CARE EMPLOYER ’s PERSPECTIVE 229

A further model of cooperation among employers is the regional or-
ganization of services with each hospital specializing in certain services. The
Robert Wood johnson Foundation is offering grants for this and other
models to help rural health providers with ﬁnancial problems.

The notion of multicompetent personnel is frequently suggested as a
solution for low-volume rural providers. There are currently a small num-
ber of programs training multicompetent practitioners. A program pro-
viding dual certiﬁcation at Southern Illinois University at Carbondale, which
was started in the 1970s, is popular with rural communities. Recently,
however, students have sought certiﬁcation in only one ﬁeld, a trend that
is thought to be the result of better pay for single-ﬁeld jobs (Cordes and
Wright, 1985). As the committee has noted, the ability to pay competitive
salaries is likely to be limited in rural locations and is dependent on reim-
bursement decisions. Still, without attractive compensation, efforts to ease
rural manpower problems will fail in the long run.

Employers who want to hire multicompetent practitioners can help by
ensuring that educators know that a demand for them exists and also by
making known the mix of competencies they need. If an individual’s ed-
ucation is tailored to an employer’s requirements, the employer can use
the practitioner efﬁciently, and thus maximize the results from his or her
salary.

The third type of problem of rural health providers—ﬁnding allied
health personnel with the special skills needed for employment in small
rural settings—can also be alleviated by linkages with educational programs.
Again, providing clinical sites for students ensures that they learn about
rural practice. Models for these programs already exist. We have already
mentioned the University of Alabama’s Linkage Program. Another is the
University of Wisconsin Medical Technology Program, which places stu-
dents in a generalist capacity in small hospital laboratories. This program
is said to have contributed signiﬁcantly to students’ interest in clinical lab-
oratories in community and rural hospitals, as the majority of students have
been employed in such laboratories after graduation (Bamberg, 1981). Still
another model offers students experience on health care teams in rural
Kentucky. Students at Kentucky Southern Community College are exposed
to rural practice and learn how to function with other members of the
health profession team (Bamberg, 1981).

One type of linkage already in place for some rural providers is mem-
bership in a multiprovider organization. Regardless of whether this or-
ganization is horizontally or vertically integrated, if it includes both rural
and urban sites, then an opportunity for innovative solutions to stafﬁng
problems exists. Rural members of the organization might negotiate ar-
rangements whereby service at or rotation through a rural location becomes
a necessary step for upward mobility in the organization’s career ladder.

230 ALLIED HEALTH SERVICES

Long-Term Care Facilities

Long-term care providers (e.g., nursing homes and chronic mental care
facilities), like rural health care providers, have special needs and charac-
teristics that make some of the strategies suggested in the earlier part of
this chapter inapplicable. For example, it is difficult to increase salaries to
attract allied health practitioners when reimbursement is extremely tight.
It is also often impossible to provide advancement paths in small facilities,
a category into which many nursing homes fall.

Chapter 8 explores some of the reasons long-term care facilities are not
seen as attractive work sites. A number of these reasons are subjective and
perceptual. Caring for elderly patients and patients with chronic or mental
diseases is seen as unsatisfactory in contrast to working with patients in
whom real and lasting improvements can be realized. Mental disturbances
in patients make practitioners’ tasks more difﬁcult and are a condition for
which their education often fails to prepare them. In the course of this
study the committee uncovered a concern among the providers of long-
term care that educators and practitioners in many allied health ﬁelds are
both unwilling and unprepared for work with elderly patients and patients
with chronic conditions. Remarks like the following were often heard:
“Physical therapists would rather work in sports medicine and with the
acute phase of trauma rehabilitation than with frail, confused, nursing
home patients.” Long-term care facilities in some regions are not perceived
as giving high-quality or sometimes even adequate care. Clearly, a long-
term, major effort is needed to change perceptions of work in the chronic
care sector. The ﬁgures in Table 6—5 suggest that, for dietitians working
part—time and for full- and part-time occupational and physical therapists,

TABLE 6-5 Average Hourly Earnings in Hospitals and Nursing and
Personal Care Facilities, 1985

 

Nursing and
.

 

Personal Care Percentage
Occupation Hospital Facilities Difference
Full-time
Dietitian $11.52 $10.69 — 7.2
Occupational therapist I 1.41 11.11 ~26
Physical therapist 11.98 13.25 10.6
Head nurse 14.37 12.40 — 13.7
Part-time
Dietitian 11.66 11.60 - 0.5
Occupational therapist 11.78 11.32 — 3.9
Physical therapist 12.71 15.63 23.0
Head nurse 14.84 11.58 — 22.0

 

SOURCE: Bureau of Labor Statistics (1987a,b).

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 231

compensation is not likely to be a decisive factor in choosing between
employment in a nursing or personal care facility and employment in a
hospital. job satisfaction, however, may be greater in acute care settings.

Lower level personnel—nursing aides and orderlies—have fewer op-
portunities in the acute care sector. Yet for these individuals the average
hourly salary of $5.15 for nursing aides in nursing and personal care
facilities might not be competitive with alternative employment in such
places as fast-food restaurants, which pay more, require no formal post-
secondary education, and in which working conditions are less stressful
(Kerschner, 1987).

Long-term care employers can try to use some of the options suggested
in the earlier section for rural health employers. Establishing links with
allied health education programs to increase curriculum content relating
to long-term care could help to deﬂect some of students’ anxieties about
serving these special populations. Similarly, providing clinical sites for stu—
dents can dispel misconceptions about the work, enhance the skills needed
to serve in long—term care, and establish ties with an employer.

An Institute of Medicine committee in 1983 recommended that edu-
cational programs for nursing should provide more formal instruction and
clinical experience in geriatrics. It was believed that this would augment
the supply of new nurses interested in caring for the elderly (Institute of
Medicine, 1983). This could also be an effective strategy for allied health
practitioners, and it is discussed further in Chapter 8.

CONCLUSIONS AND RECOMMENDATIONS

Human resources planning has not been a high priority or an integral
part of strategic planning in the health care organization. As a result, there
has been little emphasis on or investment in research and experimentation
in structuring staffing policies and working environments. Moreover, when
there is a plentiful manpower supply, there is little incentive to undertake
such an onerous task. The committee foresees, however, that the availability
of alternative employment and stable or falling enrollments in allied health
education programs will ﬁnd some employers—particularly hospitals—
unprepared to solve stafﬁng difficulties and fulfill service demands. Relying
on the government to create incentives, such as educational subsidies for
entry into professions that turn out to be poor careers, and complaining
about licensing barriers are not likely to be as effective solutions as an
investment in improved management capability. Except in the face of ap-
preciably lower operating margins, it will be difﬁcult for administrators to
make a convincing case for increased reimbursement (e.g., through the
prospective payment system) to help support salary increases without hav-
ing demonstrated to payers that management solutions have been pursued

232 ALLIED HEALTH SERVICES

to their practical limits. To date, employers have relied on new graduates
and short-term incentives to offset turnover and prolong tenure in the
work force.

The committee recommends that employers strive to increase the sup-
ply of allied health practitioners by attracting people into allied health
occupations and prolonging their attachment to their fields. Some ways
to do this include increasing compensation, developing mechanisms for
retention, and establishing ﬂexible schedules and educational opportun-
ities. Employers should also look to new labor pools that include men,
minorities, career changers, and individuals with handicapping condi-
tions.

Yet attracting and keeping individuals in allied health fields is only one
part of a strategy to relieve pressures. The committee also recommends
that chief executive officers, human resource directors, and other health
care administrators develop methods for the effective utilization of the
existing supply of allied health personnel. Such methods must grow out
of experimentation with new ways of organizing work efﬁciently and
distributing labor among skill levels while ensuring that the quality of
care is not compromised.

As the health industry looks more aggressively beyond cost savings through
reduced hospital utilization and toward technology assessment, quality as-
surance, and nonhospital utilization controls, it is appropriate that allied
health services should come under scrutiny. This scrutiny should be viewed
by management as an opportunity to work with allied health professionals
to use a scarce labor resource effectively. It is also an opportunity for the
allied health ﬁeld to help provide the research underpinning that will be
the foundation for decision making.

The committee recommends that health care providers and adminis-
trators seek innovative ways to channel limited allied health resources
toward activities of proven benefit to consumers. Agencies such as the
National Center for Health Services Research and the Health Care Fi-
nancing Administration should sponsor research and technology assess-
ment to ensure that allied health services are effective and that they are
organized efﬁciently. Associations of employers, unions, accrediting
agencies, and professional associations should assist in disseminating
research findings and providing technical assistance in their implemen-
tation.

If employers are to use limited human resources effectively, personnel
must be appropriately educated. In addition, the goals and aspirations of
new graduates should accord with the realities of life in the workplace;
otherwise, their job satisfaction is likely to be undermined. The committee
therefore strongly recommends that health care administrators and ac-
ademic administrators engage in constructive exchanges to improve the

THE HEALTH CARE EMPLOYER’S PERSPECTIVE 233

congruence of employment and education. These exchanges, which should
take place at the state and local levels, will be enhanced by the partici-
pation of educators who are also leaders of the professional associations.

Although the analyses in this study are most often based on national
data, the committee emphasizes that conditions differ among states and
even among localities. State legislators have a legitimate interest in ensuring
an adequate supply of health care personnel, educational Opportunities for
the states’ citizens, and employment opportunities for graduates of state—
supported educational programs. The committee recommends that state
legislatures establish special bodies whose primary purpose would be to
address state and local issues in the education and employment of allied
health personnel.

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7

Licensure and Other
Mechanisms for Regulating
Allied Health Personnel

 

THE CONGRESSIONAL CHARGE to this committee directed it to “investi-
gate current practices under which each type of allied health personnel
obtains licenses, credentials, and accreditation” (Appendix A, Section
223[b][3]). The committee has taken a rather broad View of this charge,
interpreting it to encompass the whole array of mechanisms meant to
ensure that allied health personnel are properly trained and competent to
practice. These mechanisms, which include licensure and other forms of
governmental regulation, voluntary certiﬁcation, and standards imposed
by health care providers and payers, are central to this study in that they
interact with and inﬂuence virtually all of the other study issues.

For example, the scope of practice for a ﬁeld that is deﬁned under state
licensing statutes and regulations affects the demand for allied health per-
sonnel by constraining how they may be used by employers. Certiﬁcation,
if it is accepted as a valid distinction by employers or if it is required by
accrediting bodies such as thejoint Commission on Accreditation of Health-
care Organizations, also affects employers’ decisions to employ allied health
personnel; certiﬁed and noncertiﬁed members of the same allied health
ﬁeld are then treated as separate labor pools. Regulatory mechanisms also
inﬂuence supply by deﬁning who may enter and remain in certain allied
health ﬁelds.

A great deal is at stake here. Health care payers rely on licensure and
other credentialing mechanisms to assist them in deﬁning eligibility for
coverage and reimbursement for allied health services. The various allied
health occupations look to these mechanisms to give them identity and
legitimacy by deﬁning the nature and length of training, requirements for

235

236 ALLIED HEALTH SERVICES

entry into the field, and the power to control certain health care practices.

In a time of great ferment in health care, these control mechanisms take
on even greater significance. The proliferation of health care occupations,
changing models of health care delivery, and new reimbursement methods,
along with cost-control efforts by industry and government, place stresses
on these controls.

To carry out this part of the congressional charge, the committee held
discussions with officials of government agencies and private organizations
responsible for the various control mechanisms. It also held a public hearing
at which 26 allied health associations and 4 experts presented testimony;
two of the experts prepared papers for the committee on state regulation
of health occupations. In addition, the committee reviewed the research
literature on occupational regulation.

METHODS OF CONTROL

State Regulation

Society applies many quality control methods to health care personnel,
including allied health personnel. The states bear the greater responsibility
in this control system. Through occupational licensure and other forms of
regulation, states exercise their authority to protect the health, safety, and
welfare of their citizens. The earliest attempts to regulate health occupations
in this country were in colonial Virginia (1639), Massachusetts (1649), and
New York (1665), when medical practice acts were enacted. By the begin—
ning of the twentieth century, the Supreme Court had validated this use
of the states’ police powers, and most states had licensed lawyers, dentists,
pharmacists, physicians, and teachers. Between 1900 and 1919, most states
also licensed nurses, optometrists, osteopaths, podiatrists, and veterinarians
(Carpenter, 1987). Before 1960, this list had expanded to include dental
hygienists, practical nurses, and physical therapists. Since 1960, only three
health occupations have come to be universally licensed: psychology, nurs-
ing home administration, and emergency medical technology. The latter
two were licensed as the result of federal legislation.

Table 7-1 shows the licensure status of the 10 allied health ﬁelds on
which this study concentrates as of June 1987. Among these ﬁelds, physical
therapists and dental hygienists are licensed in every state. Emergency
medical technicians must be certiﬁed by some agency in every state. At the
other extreme is medical record administration, for which no state requires
licensure; this ﬁeld relies instead on certiﬁcation (registration) by the Amer—{
ican Medical Records Association. All the other ﬁelds are licensed in some
states: for example, respiratory therapists are licensed in 7 states, audiol-
ogists and speech-language pathologists in 37.

REGULATING ALLIED HEALTH PERSONNEL 237

TABLE 7-1 Licensure Status of Selected Allied Health Fields

 

 

Field Licensure Status
Clinical laboratory Medical technologists are licensed in 5 states and New York
technology City. Technicians are not licensed in any state.
Dental hygiene Dental hygienists are licensed in all 50 states and the District of
Columbia. Dental assistants are not licensed in any state.
Dietetics Dieticians are licensed in 14 states, the District of Columbia,

and Puerto Rico.
Emergency medical

services Certiﬁed in all 50 states.
Medical record Neither medical record administrators nor medical record
services technicians are licensed in any state.

Occupational therapy Occupational therapists are licensed in 34 states, the District of
Columbia, and Puerto Rico. Occupational therapy assistants
are not regulated in any state.

Physical therapy Physical therapists are licensed in all 50 states. Physical therapy
assistants are licensed in 18 states.
Radiology Radiographers are licensed in 17 states and Puerto Rico.

Radiation therapy technologists are licensed in 15 states and
Puerto Rico. Nuclear medicine technologists are licensed in
10 states and Puerto Rico.
Respiratory therapy Respiratory therapists are licensed in 7 states.
Speech—language Speech—language pathologists and audiologists are licensed in
pathology/audiology 36 states and Puerto Rico.

 

SOURCE: Information from professional associations, updated t0_]une 1987.

Licensure is the most restrictive form of state regulation. Carpenter
(1987) deﬁnes licensure as “a process by which a governmental agency
restricts entry into an occupation by deﬁning a set of functions and activities
constituting a ‘scope of practice,’ grants permission to engage in that prac-
tice only to persons meeting predetermined qualiﬁcations, and establishes
structures and procedures for screening applicants and granting licenses
to practice.” These and other deﬁnitions share certain common elements,
including:

0 licensure is intended to protect the public;

0 licensure is exclusionary;

0 licensure prescribes the characteristics and qualiﬁcations of persons
who may be licensed;

O licensure deﬁnes a scope of practice for licensees (and therefore 1i—
censure laws are often referred to as “practice acts”); and

O licensure prohibits nonlicensed persons from engaging in the deﬁned
scope of practice.

Although the standard deﬁnitions focus on initial entry, licensure also
addresses standards of practice and ethical and business behavior (what it

238 ALLIED HEALTH SERVICES

takes to keep a license) and causes for disciplinary action (what it takes to
lose a license).

By long tradition, licensure has been, for all practical purposes, a form
of state—sponsored self-regulation because it has been carried out by boards
composed of members of the regulated occupation empowered to act with
a high degree of autonomy. As Shimberg (1984) noted in recounting the
history of state licensure:

These boards had broad powers to implement the law by promulgating rules and
regulations governing practice standards and professional conduct; establishing
minimum education, training, and experience qualiﬁcations; examining candidates
as to their ﬁtness to practice; investigating complaints against practitioners; and
taking appropriate disciplinary action, including suspension or revocation of a
practitioner’s license where appropriate.

Recent reforms have broadened the membership of licensure boards to
include representatives of the public who may or may not have voting
privileges. Yet, on the whole, the licensed occupations still are largely self-
regulated. This point is elaborated later in this chapter. However, licensure
carries with it a whole array of regulations and administrative procedures
for implementing the state statutes.

States can and do use a number of modes of occupational regulation
other than licensure (Table 7—2). Among the .10 allied health ﬁelds covered
in this report, title protection “through registration or certiﬁcation by the
state is the most frequently used form of regulation other than licensure.
This regulatory mechanism is also applied in other ﬁelds such as accoun-
tancy, in which anyone can practice but only those who have met state
standards can use the title “certiﬁed public accountant.” In one form or
another, about 800 occupations are regulated by the states, including ar-
chitects, real estate brokers, barbers and cosmetologists, electricians, and
engineers.

Besides occupational regulation, states also oversee allied health person-
nel through the regulation of institutions and settings in which they work.
Requirements for the licensure of hospitals and nursing homes include
personnel standards. In addition, states have other laws and regulations of
broad applicability in place, such as those that govern business practices
and provide consumer protection, that may be used against incompetent
or unscrupulous allied health personnel. The states also deﬁne qualiﬁca-
tions for civil service positions held by these personnel.

Consumers may use the tort system in any state to ﬁle civil suits to seek
compensation for malpractice by allied health personnel. Presumably, this
mechanism carries some deterrent effect; in the context of quality assur-
ance, however, it must be viewed as a last resort.

REGULATING ALLIED HEALTH PERSONNEL 239

TABLE 7-2 Modes of Occupational Regulation

 

l.

PRACTICE STANDARDS

Without special enforcement

Through the adoption of statutes and rules, this mode can establish restrictions on
the practice of an occupation with civil or criminal penalties enforceable through the
courts. This type of regulation requires no inspections, registration, or special
enforcement staff. Rather, it relies on action by the harmed parties or by a consumer
affairs office.

With special enforcement

Through statutes, or rules, or both, this mode can establish restrictions on the
practice of an occupation in addition to establishing inspections, enforcement
mechanisms, and penalties. However, this mode does not require registration,
certiﬁcation, or any assessment of the practitioner’s credentials or competency.

. REGISTRATION

Without standards

Through regulation, a state agency can require persons in an occupation to register
and supply certain information without requiring any standards, testing, or
enforcement.

With standards

It is also possible to have a registration requirement in combination with minimum
practice standards that are set by a designated agency. Although registration would
not be exclusionary, it would subject registrants to minimum standards and thereby
provide some protection to the public.

. STATL'TORY CERTIFICATION

With state standards and state enforcement

Through regulation, occupational members can be required to meet certain state
standards; only those who meet these predetermined qualiﬁcations may legally use
the designated title of the occupation, This mode entails standards, testing, codes of
practice, possible inspections, and enforcement.

With private standards and assessment and state enforcement

Through regulation, an agency of the state may require members of an occupational
group to meet certain standards established by a private testing or assessment center
or organization (reviewed by the state), with the state handling the certiﬁcation and
any enforcement required. Legally, the state is responsible for the standards set and
for monitoring the process.

. STATUTORY CERTIFICATION AND PRACTICE STANDARDS

A state may establish, by rule, certiﬁcation for an occupation and also request the
legislature to pass a law that would establish practice standards for that same
occupation. This combination would establish a system of title control for those
meeting certain required standards of competency, as well as establishing standards
of practice for anyone who practices the occupation.

. REGULATION THROUGH SUPERVISION BY AN ALREADY LICENSED PRACTITIONER

Certification with standards

Through statutes and rules, an occupation can be certified and required to work
under the supervision of an already licensed occupation; standards for practice can
also be established. Continued

240 ALLIED HEALTH SERVICES
TABLE 7-2 Continued

 

Through standards of practice but without certification

It is also possible to regulate by providing that the occupation be performed under
the supervision of a licensed professional with certain standards set forth but without
requiring that the individual be certified.

6. LICENSURE
Licensure is the most restrictive form of occupational regulation, providing for both
title control and an exclusive area of practice. It requires standards of practice,
education, knowledge or minimum competency, and inspection and enforcement
with civil and criminal penalties.

SOURCE: Goldman and Helms (1983).

 

Criticisms of State Regulation

Occupational regulation has been in ferment for at least 20 years. Crit—
icisms have come from a number of quarters, and these criticisms have
given rise to recommendations for reform. Some changes have occurred
as a consequence.

In the 19605 the source of concern was access to health care. With an
apparent shortage of physicians, there was concern that restrictive licensing
laws were hampering the effective deployment and utilization of physicians’
assistants and other physician extenders. This issue was addressed by the
National Advisory Commission on Health Manpower in its 1967 report.
At the direction of Congress in the Health Training Improvement Act of
1970, the US. Department of Health, Education, and Welfare’s Ofﬁce of
the Assistant Secretary for Health and Scientiﬁc Affairs investigated prob-
lems in health care personnel licensure and certiﬁcation. The department’s
1971 Report on Licensure and Related Health Personnel Credentialing
contained far-reaching recommendations, including a recommendation to
the states for “a two—year moratorium on the enactment of legislation that
would establish new categories of health personnel with statutorily-deﬁned
scopes of functions.” The moratorium was to allow time for further con-
sideration of the tasks and functions of new health care occupations.

Questions about the wisdom of occupational licensure still remain, al—
though the circumstances today are different. The perceived shortage of
doctors and dentists has changed to a perceived surplus, and the number
of newly emerging health care occupations is increasing. Since the early
1970s the issue of rising health care costs has taken on greater and greater
importance. In the context of cost containment, the fact that more and
more health occupations have been seeking statutorily protected scopes of
practice is worrisome. This proliferation is seen as contributing to inefﬁ-
ciencies in the health care industry, especially in view of the rapidity of
technological change.

REGULATING ALLIED HEALTH PERSONNEL 241

Allied health personnel are affected by this tension. Many of the allied
health ﬁelds are new, and, according to the example offered by older, well-
established ﬁelds such as medicine, nursing, and dentistry, state licensure
is crucial to their achieving recognition as professions. Licensure, it is be-
lieved, gives legal validation to the ﬁeld’s unique status. It provides a way
of excluding unqualified practitioners from providing services; it gives
ofﬁcial recognition to the ﬁeld’s scope of practice; and it offers easily ver-
ified credentials that can be used by employers and health care payers
(McCready, 1982). Licensure is also considered to be necessary to avoid
being subject to prosecution. For example, physicians would be vulnerable
to prosecution for practicing medicine without a license, since many medical
practice acts are so broad that physicians are granted virtually unlimited
scopes of practice.

Above all, state regulation is viewed as a means of improving the quality
of health care by restricting entry into health care occupations to persons
who have proper credentials and by disciplining persons who do not meet
standards of professional behavior. Much of the criticism leveled at reg-
ulation is based on the lack of evidence on this point.

Criticism; of Structure and Process

The traditional regulatory structures and processes, which were devel-
oped in the last century, are criticized as anachronistic and inconsistent
with the public policy objective of protection of the public.

By long tradition, the regulation of a health occupation, given a practice
statute, is the responsibility of a board. The composition of the board is
usually deﬁned in the statute. One of the strongest criticisms of the reg-
ulatory structure is that these boards are not sufﬁciently accountable to the
larger public. Until recently, they were composed entirely of members of
the regulated occupation, drawn from the membership of their related
associations. In many states, they generated their own revenues by charging
fees to candidates and licensees; they had their own staffs; they were often
located in the home of the board’s secretary; and they had considerable
rule-making authority with little or no oversight. Their proceedings were
Closed to the public, as were their records.

By statute, the regulatory boards are charged with setting entry require-
ments, practice standards, and codes of conduct, and with disciplining
licensees who fail to meet those standards and codes. The performance of
these functions has also been subject to criticism.

Eligibility standards are deﬁned in terms of education and, in some cases,
experience. Boards also require entrants to pass an examination that, in
some cases, is devised by the board. In other cases, the board relies on a

242 ALLIED HEALTH SERVICES

national examination or commissions a testing organization to develop a
state exam. Criticisms that have been leveled at entry requirements are that
they are inﬂexible, offering only one path to entry; that education and
experience requirements are unrelated to the demands of practice; that
educational requirements rest heavily on accreditation, which in turn is
controlled by the professional associations; that examinations are not valid
reﬂections of “real—world” practice requirements; and that the common
practice of “grandfathering” current practitioners when licensing a new
occupation is inconsistent with the goals of protecting the public health and
welfare.

“Standards of practice” are deﬁned in terms of behaviors that are subject
to disciplinary action, including fraud and deception in obtaining the li-
cense; conviction ofa felony; engaging in unacceptable patient care through
deliberate or negligent acts; knowing violation of the practice act; contin-
uing to practice although unﬁt; and lewd or immoral conduct in the delivery
of services. “Codes of conduct” most commonly prohibit business practices
that are considered unacceptable professional behavior. Traditionally, these
have included advertising; practice in chain or department stores, shopping
centers, or other commercial environments; and engaging in competitive
bidding.

Disciplinary procedures are usually deﬁned in the statute. In some states
and for some occupations, revocation of a license is the only sanction
provided. In others, the statute deﬁnes an array of sanctions of varying
degree, including license suspension, censure, and reprimand.

Boards have been criticized for the way they carry out their disciplinary
responsibilities: they only investigate complaints of incompetence or im-
propriety, rather than performing any independent monitoring. Impro-
priety (i.e., violation of the code of ethics) is more frequently the basis for
disciplinary action than is incompetence. The number of disciplinary ac-
tions is extremely low in comparison with estimates of the incidence of
incompetent practice. The public is not informed of disciplinary actions
against licensees. A partial explanation for the historical lack of disciplinary
vigor is the inadequacy of the resources available to the task of investigating
and “prosecuting” complaints. Without sufﬁcient staff and budget, the
regulatory process is more bark than bite.

“Turf” monitoring and turf protection occupy a signiﬁcant portion of
the energies of a state’s regulatory apparatus. The various occupations
battle among themselves over which parts of health care and which parts
of the patient fall under their jurisdiction. These battles are fought by
establishing practice acts and by implementing rules and regulations. Yet
this is not the only theater of conﬂict; insurance coverage and reimburse-
ment constitute another. Yet the regulatory arena is where the identity and
power of allied health personnel are largely determined.

REGULATING ALLIED HEALTH PERSONNEL 243

In carrying out this study the committee encountered many examples
of jurisdictional struggles among allied health and other occupations, strug-
gles that caused their roles to be constantly shifting. For instance,

0 ophthalmic medical assistants versus optometrists on performing re-
fractions;

. surgical technologists versus nurses on who should perform various
tasks in the operating room;

0 orthoptists versus physical therapiSts on fitting braces and other or-
thotic devices; and

O audiologists versus hearing aid dispensers in hearing testing.

These struggles, in which one occupation seeks to expand its realm of
control at the expense of another, are a constant element of regulating
health services through licensure. In many cases the issue is which occu-
pation is entitled to perform a speciﬁc function. In others, the issue is which
occupation or occupations have jurisdiction over some portion of the hu-
man anatomy. In still others the issue is under what conditions persons in
an occupation perform their functions. For example, in many states, phy-
sician referral is required for physical therapy or occupational therapy but
not for speech therapy. Another important condition of practice is the level
of supervision required. These referral and supervision provisions in li-
censure statutes deﬁne the degree of autonomy of health care workers on
the one hand and their degree of availability to consumers on the other.
Decisions on these issues by state legislators and regulatory bureaucracies
affect the costs, quality, and accessibility of health care services.

The great difﬁculty facing state decision makers is that the impact on
costs, quality, and accessibility of any proposed modiﬁcation in a health
occupation’s scope of practice, referral, or supervision is rarely clear. The
risks and beneﬁts of change are often hypothetical, difﬁcult to measure,
and subject to large differences in judgment. Rhetoric and political power
frequently substitute for evidence and rational decision making. Rarely are
rigorous studies done.

One of the clearest examples of this problem is the case of dental hygiene
services. In the course of testimony by representatives of the American
Dental Hygienists’ Association (1987a,b) and the American Dental Asso-
ciation (1987) before the committee, committee members learned of the
continuing controversy over the required levels of supervision of dental
hygienists by dentists.

In general, dental hygienists are only permitted to practice (i.e., perform
a variety of chieﬂy preventive services—eg, cleaning teeth, taking x rays,
applying topical fluorides, and teaching proper dental hygiene) under the
supervision of a licensed dentist. The supervision may be “general,” which
means that a dentist may delegate a given function. The dentist must be

244 ALLIED HEALTH SERVICES

responsible for its successful performance but does not have to be physically
present while the delegated function is carried out. Alternatively, the su-
pervision may be “direct,” meaning that the dentist must be present in the
same room as the hygienist, or “indirect,” which requires only that the
- dentist be present in the treatment facility.

Supervision requirements vary among the states. According to the Amer—
ican Dental Hygienists’ Association (1987b), 38 states permit dental hy—
gienists to practice at least some preventive oral health services under
general supervision. In some states, general supervision is limited to hos-
pitals, nursing homes, adult day care centers, and other institutional set-
tings. In Washington State, dental hygienists have practiced unsupervised
in long-term care facilities since 1984.

The American Dental Association is seeking to tighten supervisory re-
quirements for hygienists. In 1986 the association’s House of Delegates
passed a resolution opposing general supervision and urging state dental
societies to eliminate it from state practice acts. Th same resolution urged
that, in instances in which general supervision cou d not be removed from
the statute, the regulations be changed to require that:

a. any patient treated by a dental hygienist ﬁrst become a “patient of
record” of a licensed dentist;

b. dental hygiene services be given prior authorization by a dentist no
more than 45 days before the services are provided; and

c. the dentist examines the patient within a reasonable time after the
dental hygiene services are provided.

The justiﬁcation for this resolution was that general supervision endan-
gers the dental health of the public. Its effect would be to increase dentists’
control of dental hygiene services.

Since the resolution was passed, efforts have been made in several states
to delete general supervision. A bill to this effect was introduced in Con-
necticut in 1987. In Texas, where general supervision has been permitted
for over 30 years, the Board of Dental Examiners proposed rules that
would require direct supervision of all dental hygiene functions (American
Dental Hygienists’ Association, 1987b). The Virginia Dental Board, which
had been on the verge of liberalizing supervision requirements, decided
against such action.

Other states are moving to relax their supervision requirements so that
dental hygiene services can be provided without the dentist’s physical pres-
ence. Legislation to this effect has been proposed in Missouri, Ohio, South
Carolina, and Wisconsin. At the extreme on this continuum is Colorado,
which in 1986 became the ﬁrst state to allow dental hygienists to provide
most of their basic functions without supervision by a dentist. Other func-
tions, which are designated as “supervised dental hygiene,” require a den-

REGULATING ALLIED HEALTH PERSONNEL 245

tist’s supervision. Diagnosis, treatment planning, and prescription of
therapeutic measures continue to be the responsibility of dentists. The
statute imposes disciplinary action on dental hygienists who fail to refer
patients to a dentist when the treatment needed is beyond their scope of
practice. A lawsuit to overturn the statute failed but is under appeal.

In California, 15 dental hygienists are allowed to clean and examine
teeth without the supervision of dentists. This demonstration program is
one of the state-sponsored Health Manpower Pilot Projects, under which
the requirements of state practice acts may be waived for experiments with
innovative methods of health care delivery. According to the California
Ofﬁce of Statewide Health Planning and Development (1987), the agency
responsible for the program, it “is authorized to approve locally conceived
and implemented demonstration projects to prepare and utilize health
personnel for new or expanded roles.”

To qualify for the program, hygienists needed at least 4 years of clinical
experience, certiﬁcation in cardiopulmonary resuscitation, and special training
in instrumentation. They are currently providing services in ofﬁces and in
other settings such as nursing homes. Some make house calls to people
who are bedridden. Their case records are reviewed by a dentist.

The California Dental Association sued to halt the program on the basis
that it was a threat to public health and that the procedures followed by
the state and by California State University in approving and implementing
the program were inadequate. In August 1987 Judge Rothwell B. Mason
of the Sacramento County Superior Court ruled against the dental asso-
ciation. His opinion was that the program was consistent with the legisla-
ture’s intent to enable experimentation with new kinds and combinations
of delivery systems and the need for exemptions from the healing arts
practice act to permit such experimentation (California Dental Association v.
Ofﬁce of Statewide Health Planning and Development et al., Proceedings, August
28, 1987, California Superior Court, County of Sacramento).

In neither the Colorado nor the California cases were the substantive
issues resolved; both cases, to date at least, have hinged on procedural
matters. In neither case were any data or research ﬁndings presented to
support arguments about risks or beneﬁts. In addition, no evidence was
presented on the issue of what dental hygienists’ training includes and what
types of responsibilities hygienists are prepared for, on the issue of acces—
sibility of services, or on the costs of services.

In its testimony to this committee the American Dental Association (1987)
stated that it “believes that all segments of the public should receive the
same high standard of dental care.” The association expressed its concerns
about the great responsibility placed on dental care providers by the need
to diagnose nondental diseases that manifest symptoms in the mouth and
the need to provide services to patients who are severely medically com—
promised (American Dental Association, 1987).

246 ALLIED HEALTH SERVICES

The committee questioned the American Dental Association spokesper-
son about those circumstances, such as practices in public schools, in which
it would be beneﬁcial to allow hygienists to provide prophylactic services
to children who had been examined by a dentist but without the dentist
being present. The association’s ofﬁcial position is that this form of delivery
is not acceptable (Institute of Medicine, Committee to Study the Role of
Allied Health Personnel, 1987).

The situation in dentistry is not unique. It illustrates issues of cost, quality,
and access to health care services that are common to many health care
ﬁelds. The committee is concerned that such issues are faced by the courts,
state legislatures, and regulatory agencies with neither a body of statistical
evidence nor the informed judgments of knowledgable, disinterested par-
ties available for guidance. Without such information, there is considerable
risk that decisions will be made on purely political and economic grounds.

Criticisms as to Outcome

In addition to criticisms of the structures and processes of'state regu-
lation, there have been substantial criticisms of the outcomes of regulation
in terms of health care cost, quality, and accessibility. A body of research
literature generally calls into question whether state regulation as we know
it is serving the public. The literature shows with some consistency that the
costs (prices) of health care services and products (e.g., eyeglasses, dentures)
are higher in states with more stringent regulation (Begun, 1981; Gaumer,
1984). The incomes of health professionals are also higher in states that
restrict the activities of their substitutes and auxiliaries.

Higher consumer prices presumably reduce access to health care by
keeping some consumers out of the market entirely. There is also direct
evidence that restrictions——for instance, on practice setting—may reduce
the quantity of services provided. Begun (1981), for example, found that
optometrists practicing in chain outlets conducted more eye examinations
in a day than optometrists in private ofﬁces. Many states prohibit practice
in chain outlets.

The effects of restrictions on quality of care are less clear, largely because
of the great difﬁculty in obtaining data with which to assess quality. This
is unfortunate, because quality is central to the policy debate over the extent
and nature of occupational regulation. The various health occupations
argue for instituting regulations, for changing their scope of practice, and
for limiting the scopes of other occupations entirely on the grounds of
quality of care.

As Begun (1981) points out, in this context, “quality” is ill-defined: “it
may refer to the degree of respect for the professional, the degree of
communication or humanism in the professional—client relation, the tech-
nical sophistication of the service, or the actual outcome of the service.”

REGULATING ALLIED HEALTH PERSONNEL 247

Other possibilities include the professional’s number of years of training,
the degree of trust the client has for the professional, and the degree of
client satisfaction.

However quality is measured, its relationship to regulation is equivocal.
For example, studies by Maurizi (1974) and by Carroll and Gaston (1977)
have suggested that quality is actually lower with greater regulation. On
the other hand, Holen’s (1977) study of dentistry showed that more strin-
gent state licensing standards reduced the probability of adverse outcomes.
Gaumer (1984) concluded from a review of the literature that state reg-
ulation could not be shown to reduce the risk of health care personnel
making mistakes or errors in judgment, nor in general ensure competence.
Begun (1981) showed that restrictions on optometric practice are associated
with higher quality, higher cost, and lower accessibility. Yet quality was
measured in terms of duration of eye examinations and their complexity,
so the result might be attributable to fewer “low-quality” exams being done
rather than to more “high-quality” exams.

Criticisms of the outcomes of state regulation are also aimed at its effect
on geographic and career mobility. There is considerable research to sug-
gest that state licensure, especially with limited reciprocity, limits the geo—
graphic mobility of licensed personnel. It also limits career mobility by
prohibiting advancement from one level to another and by prohibiting
occupational change without additional education. The difficulty of trans-
ferring credits and of obtaining credit for skills acquired on the job means
that “initial career choices create a pathway which can be left only by tracing
one or more steps backward and essentially starting from an entry level
once more” (Carpenter, 1987).

Reform of State Regulation

Twenty years of criticism have led to a number of recommendations for
the reform of state regulation of health occupations, some of which have
been implemented.

Criteria for Regulation: “Sunrise" Procedures In the face of a growing
number of occupations seeking licensure and a growing concern about the
cost—effectiveness of licensure, 13 states have sought to bring a greater
degree of reason and due process to what had been largely an ad hoc and
political procedure. Minnesota was the ﬁrst state to enact sunrise legislation
in 1973. The Minnesota example, criteria from the Council of State Gov-
ernments, and principles emanating from the US. Department of Health,
Education, and Welfare have been used as guidelines in these efforts.

The criteria in general have been similar. Basically, they consist of a set
of guidelines to use in deciding whether an occupation should be regulated
and another set for deciding on the most appropriate form of regulation.

248 ALLIED HEALTH SERVICES

Criteria for regulating an occupation include evidence of harm from
unregulated practice, evidence that the occupation involves specialized skills,
and evidence that the public is not protected by any other means. More
recently, a criterion of cost-effectiveness has been added by some states.
Minnesota’s statute and current regulations (see Appendix F) are an ex—
ample of these criteria. The rules spell out in some detail what constitutes
evidence of harm, including the kinds of harm that are recognized and
how to assess the potential for harm, and the extent of danger inherent
in the occupation’s functions.

Minnesota’s regulations also appropriately recognize the rather long list
of “other means” for protecting the public: supervision by other practi-
tioners, state or federal laws governing devices and substances, employment
in licensed facilities, federal licensing or other requirements, civil service
procedures, or national certiﬁcation procedures. A consideration of these
other means not only guides the initial decision to regulate at all but can
also guide the design of the appropriate regulatory mechanism when one
is needed.

The criteria for selecting the mode of regulation follow the principle of
using the least restrictive activities consistent with public protection (see
Subdivision 3 of the Minnesota statute, Appendix F). The least regulatory
mode is the strengthening of the base for civil action or criminal prohi—
bitions, or both. This is essentially a reliance on the deterrent effect of
potential civil actions or criminal penalties. The most regulatory mode is
occupational licensure, which prohibits persons who do not meet the state
standards from engaging in practice. An intermediate mode is the estab-
lishment of title protection through registration or certiﬁcation.

Certiﬁcation has been used for many years in the ﬁeld of accountancy.
Accountants are certiﬁed by the states after meeting certain eligibility cri-
teria. These criteria vary among the states, but all states require passing
grades in each of four parts of the uniform national examination given by
the American Institute of Certiﬁed Public Accountants (CPAs). Some states
have education requirements; some also require experience in public ac-
countancy. Certiﬁed status allows an accountant to offer independent judg-
ment about an organization’s ﬁnancial records, the value of its assets, and
so forth. In general, large organizations have their ﬁnancial accounts au-
dited and evaluated by CPAs. A lender generally requires an audited state-
ment from a ﬁrm seeking a loan. The Securities and Exchange Commission
requires an audited statement before approving a stock offering. In these
capacities, CPAs wield considerable influence, their expertise is widely un-
derstood and respected, and they can command substantial salaries.

On the other hand, a person can prepare a ﬁrm’s ﬁnancial statements,
complete tax returns, and perform most accounting functions without being
certiﬁed. Unless a company wants to borrow money or sell shares to the
public, it does not have to pay for the services of a CPA. An individual

REGULATING ALLIED HEALTH PERSONNEL 249

taxpayer is not required to have his or her tax return prepared by a CPA.
Thus, there are lower cost options available for a wide variety of accounting
services. Using these lower cost and presumably lower quality options is
not without risk; an individual might be ﬁned by the Internal Revenue
Service or see his or her company fail because of poor accounting services.
However, in this ﬁeld, consumers are able to weigh the risks and beneﬁts
and to choose among an array of providers, based on the importance they
place on certiﬁcation and their ﬁnancial constraints.

The concept of economic impact is relatively new in this arena. It makes
explicit a concern that the imposition of regulation, whatever its beneﬁts,
carries with it certain costs to society. These include any increases in the
cost or price of services, insurance premium costs, the costs of additional
training, and the costs of operating the regulatory mechanism itself. In
some states, these regulatory operating costs are defrayed wholly or in part
through licensing fees and thus do not get charged to the consumer. In
evaluating the regulatory burden, however, these costs are signiﬁcant, ir-
respective of how they are ﬁnanced. There is probably merit in having
them made public, even if they are paid through licensing fees, as a means
of focusing attention on how much regulation costs society.

An economic impact statement requirement is very useful. It could and
should be expanded to a broader “environmental impact” statement to
incorporate other criteria such as access and quality into the considerations.
This broader statement would encourage allied health occupations seeking
state regulation, other parties at interest, and the states themselves to make
as explicit as possible the nature of the trade-offs under consideration.

Reform of the Regulatory Structure and Process

The criticisms enumerated above have led to calls that date back to the
late 19605 for structural and procedural changes. These recommendations
for change have been aimed at increasing the public accountability, efﬁ-
ciency, and effectiveness of state regulatory boards.

Board Composition Widening the membership of regulatory boards has
been one of the most consistent recommendations made by critics of state
occupational regulation (e.g., Public Health Service, 1977; Begun, 1981;
Cohen, 1980; Shimberg, 1982). As stated by Tuohy (1976, cited in Begun,
1981, p. 94), “Governments cannot continue to expect that coherent public
policy can be achieved by dealing with professional groups as if they were
the ‘owners’ of their respective technologies.” The need for public input
has generally been associated with consumer involvement, that is, the in-
clusion of one or more “lay” members on each licensure board. A number
of states have taken this step. These lay members generally are consumers

250 ALLIED HEALTH SERVICES

(much of the impetus for having them came from the consumer move-
ment); they may or may not have full membership status—voting privileges,
for example.

Although informed consumers have a great deal to offer to the regu—
latory process, there is some question about whether the addition of l or
2 consumers to a board with 8 or 10 members ofa regulated ﬁeld, especially
if the consumers cannot vote, will have the desired effect of making the
board more accountable to the public. More far-reaching recommendations
to this end include:

0 Drawing the “public” board members from the appropriate state agency.
Bureaucrats would have the advantage of ( 1) technical knowledge relevant
to the task, and (2) a power base from which to exert leverage on other
board members. The power would flow from the agency head and, ulti-
mately, the governor (Cohen, 1980).

0 Drawing a majority of the board members from outside the regulated
occupation. A far cry from one or two “token” consumers, under this
proposal boards would be dominated by lay members (Begun, 1981).

0 Drawing board members entirely from persons outside the regulated
occupation. Board members could be not only consumers but others with
relevant expertise in such ﬁelds as education, public health, economics,
health administration, and health services research (Cohen, 1980).

In the last case, the board could employ as consultants either individuals
or a panel of technical advisors drawn from the regulated ﬁeld. However,
because no member of the board would come from the ﬁeld and because
board members would have considerable relevant expertise of their own,
they would be likely to avoid “capture” or domination by the field and its
association(s).

Location of Boards in the State Administrative Structure A second major
recommendation to improve accountability has been to strengthen the
connections between regulatory boards and one or more state agencies.
One approach has been to centralize the administrative support, including
recordkeeping, the investigative staff, and other common functions of boards
in a single state agency, either the health department or a special depart-
ment established for this function.

Another approach, recommended by Selden (1970), is to have a single
board that regulates all health occupations and that is linked to a state
agency that provides all administrative, analytical, and investigative support.
Subcommittees from each ﬁeld would develop policies for that ﬁeld, subject
to approval by the full board.

A third approach is to link related health occupations through joint
boards. Rather than the single board envisioned by Selden, there would

REGULATING ALLIED HEALTH PERSONNEL 251

be a number of boards but considerably fewer than the number of regulated
occupations. Virginia is moving in this direction with a proposal for a joint
board for several allied health occupations.

Structural changes in the direction of greater accountability are highly
desirable. To be fully effective, however, they should apply to all health
occupations, not just to those that are the newest. States will need to examine
and probably revise their practice acts for physicians and other health care
professionals and to review the structures of regulation for those fields. A
double standard, one applicable to allied health ﬁelds and one to medicine,
dentistry, and nursing, is not desirable.

Information for the Public The regulatory process has been criticized for
being conducted virtually invisibly. Not only has doing business in a closed
fashion been a barrier to public accountability, it has kept the regulatory
process from serving an important educational function. Through state
regulation the public could become much better informed about the dif-
ferent health care occupations, their credentials, and the services they offer.
Public education could also increase state citizens’ awareness of the im-
portance of occupational regulation. Such awareness would be likely to
elicit greater interest and participation.

No single model for accountability is obviously superior to all others.
Each state should use its own mechanisms consistent with the objective of
cost-effective public protection.

The Federal Role

The federal government plays a very important role in regulating allied
health personnel. Although it does not regulate health occupations directly,
it has indirect inﬂuence on state regulatory policy by supporting evaluation
research, sponsoring policy analyses, and fostering information dissemi-
nation. It has direct responsibility for setting standards for eligible providers
under Medicare, however, and a shared responsibility with the states for
standard setting under the Medicaid program. Medicare conditions of
participation, which apply to all institutional providers of health services,
are a powerful regulatory tool because providers that do not meet the
conditions may not receive payment from the program except in emergency
circumstances. These regulations can be used to define the qualiﬁcations
of allied health personnel working in participating hospitals, nursing homes,
and other health care institutions.

The federal influence is also exerted by the actions of the Federal Trade
Commission. The commission has conducted and sponsored research on
the effects of regulation and has struck down certain anticompetitive prac-
tices of regulatory boards such as prohibitions on advertising.

252 ALLIED HEALTH SERVICES

The federal government has taken an important leadership role in health
occupations regulation. Reports issued by the US Department of Health,
Education, and Welfare in the 19705 were inﬂuential in drawing attention
to problems in the mechanisms of state regulation. Recommendations from
those reports and from studies sponsored by the Labor Department helped
shape the new directions in state regulation.

The Bureau of Health Professions has supported studies of occupational
roles that are useful in devising entry and practice standards. The bureau
has also helped develop and disseminate information on state regulatory
activities through its support of the Clearinghouse on Licensure, Enforce-
ment, and Regulation of the Council of State Governments.

In addition, the bureau has supported the National Commission for
Health Certifying Agencies (NCHCA), a body that sets standards for or-
ganizations that certify allied health personnel. NCHCA sets standards that
are designed to ensure that certifying agencies are accountable to individ-
uals seeking certiﬁcation, to their employers, to health care payers, and to
the public. (A copy of their standards is attached as Appendix G.)

The federal Medicare program has a signiﬁcant impact on allied health
personnel through the way it deﬁnes covered services. By means of reg-
ulation, the secretary of the Department of Health and Human Services
can deﬁne the qualiﬁcations (e.g., licensure) of personnel providing services
such as physical therapy, occupational therapy, and speech therapy.

Private Control Mechanisms

Private recognition of competence also offers some assurance to the
public; it may take several forms. Membership in an association is an in-
dication that an individual has met certain standards for admission. The
standards may include qualiﬁcations of education or experience, moral
character, and so on. In a number of allied health ﬁelds, a basic requirement
of membership is graduation from an education program approved by
CAHEA. Dental hygiene programs are accredited by the American Dental
Association. Physical therapy education programs are accredited by the
American Physical Therapy Association.

Certiﬁcation by a private agency or association generally imposes more
rigorous standards than those required for association membership. Cer-
tiﬁcation has been deﬁned as:

. . . the process by which a nongovernmental agency or association grants recog-
nition to an individual who has met certain predetermined qualiﬁcations speciﬁed
by that agency or association. Such qualiﬁcations may include graduation from an
accredited or approved training program, acceptable performance on a qualifying
examination, and/0r completion of some speciﬁed amount or type of work expe-
rience. (Shimberg, 1984)

REGULA TING ALLIED HEALTH PERSONNEL 253

In a paper prepared for this committee, Carpenter (1987) notes that cer—
tiﬁcation establishes “standards of competence” and then grants an indi-
vidual a certiﬁcate allowing them to use an occupational title, for example,
“registered dietician.” (“Registered” is a very confusing term because it may
be used to mean licensed, as with registered nurses, or certiﬁed, as in this
case.) This mechanism is, of course, analogous to certiﬁcation by a state,
except that it does not include legal prohibition against the use of the title
by persons not meeting the standards.

Historically, licensure has been concerned with minimum competency,
whereas certiﬁcation has been reserved for those meeting considerably
higher standards. In medicine, for example, certiﬁcation by a speciality
board was (and is) viewed as a “badge of excellence” (Shimberg, 1984).
This distinction is less clear—cut today, when in some ﬁelds certiﬁcation
attests to basic entry standards and in others it attests to special achievement.

Two forms of private accreditation are used as quality assurance mech-
anisms for allied health personnel. In the context of credentialing allied
health personnel, accreditation most commonly refers to a process through
which a private association or agency “grants public recognition to a school,
institute, college, university, or specialized program of study having met
certain established qualiﬁcations or standards” (Shimberg, 1984). Educa—
tional accreditation is a form of peer review that is meant “to provide a
professional judgment of the quality of the educational institution or pro-
gram” (Committee on Allied Health Education and Accreditation, 1987).

The second form of accreditation that is a quality control mechanism
for allied health personnel is the accreditation of hospitals and nursing
homes by the joint Commission on the Accreditation of Health Care Or-
ganizations. The joint commission promulgates standards that include qual-
iﬁcations of key hospital personnel. Many of these standards apply to allied
health personnel (see Table 7-3).

CONCLUSIONS AND RECOMMENDATIONS

In light of potential future shortages of allied health personnel and the
need to ﬁnd a reasonable balance between health care costs and quality,
the committee believes that it is important to maintain ﬂexibility in the use
of existing personnel and a variety of routes of entry for new personnel.

It appears that widespread use of licensure carries with it higher costs
to consumers, reduced access to health care services, and reduced ﬂexibility
for managers. People in health care careers are inhibited from changing
ﬁelds and from advancing within their ﬁelds by rigid requirements imposed
by state regulatory mechanisms. Although these control mechanisms are
designed and carried out in the stated interest of protecting the health and
welfare of the public, their effectiveness in this regard has been mixed at
best.

254 ALLIED HEALTH SERVICES

TABLE 7-3 Joint Commission on Accreditation of Healthcare
Organizations’ Accreditation Standards for Hospitals

 

 

Field Summary of Relevant Standards (if any)
Clinical laboratory The director is a member of the medical staff and preferably a
technology board-certified pathologist. There are sufficient qualified

laboratory technologists and supportive staff to perform the
required tests. A qualified technologist is a graduate of an
approved medical technology program or has equivalent
education, training. and/or experience; meets current legal
requirements of licensure/registration; and is currently

competent.

Dietetics A qualified dietitian dispenses the nutritional aspects of patient
care and ensures that quality nutritional care is provided to
patients.

Medical records A hospital must employ or have as a consultant a registered

record administrator or an accredited record technician. If
consultants only are used, medical record supervisors are to
demonstrate competence

Physical therapy See rehabilitation services.
Occupational therapy See rehabilitation services.

Radiology The director of the radiology service is to determine the
qualifications and competence of department personnel; at
least one qualiﬁed radiologic technologist is available; a
technologist does not independently perform diagnostic
ﬂuoroscopy except under certain circumstances.

The director of the nuclear medicine service is to determine
the qualifications and competence of department personnel
who are not independent practitioners.

“When radiation oncology procedures are performed in the
hospital, designated qualified technologists are assigned as
needed."

Rehabilitation services Each individual providing physical rehabilitation services must
meet relevant licensure, certification, or registration
requirements. Separate services are defined, including
occupational therapy, physical therapy, prosthetic and
orthotic services, psychological services, recreation therapy,
social work services, speech—language pathology or audiology
services, and vocational rehabilitation services. No specific
stafﬁng standards are given beyond the general one.
Separate standards require that comprehensive rehabilitation
services be provided “in an interdisciplinary manner,” and
that the quality and appropriateness of these services be
monitored and evaluated.

REGULATING ALLIED HEALTH PERSONNEL 255

TABLE 7-3 Continued

Field Summary of Relevant Standards (if any)

 

 

Respiratory therapy Respiratory care services are to be provided by a sufﬁcient
number of qualiﬁed persons under competent medical
direction. If warranted, services are supervised by a technical
director registered or certiﬁed by the National Board for
Respiratory Therapy, Inc. Other qualiﬁed personnel may
provide services commensurate with their training,
experience, and competence; these include registered
respiratory therapists or certified technicians; persons with
equivalent education or experience; qualiﬁed
cardiopulmonary technologists; and appropriately trained
licensed nurses.

SOURCE: Accreditation Manual for Hospitals (1988).

 

Statutory certiﬁcation, which legally reserves the use of a title to persons
with speciﬁc qualiﬁcations, affords most of the beneﬁts of licensure and
avoids many of the costs. In conjunction with public education, it gives
consumers the opportunity to choose among providers knowledgeably. It
does not prevent consumers from choosing lower quality or lower cost
alternatives. It permits institutional employers some ﬂexibility in their staff-
ing. It permits innovation—new careers may provide new cost-effective
methods of diagnosis and treatment.

The committee recommends statutory certiﬁcation for ﬁelds in which
the state determines there is a need for regulation because this form of
regulation offers most of the benefits of licensure with fewer of its costs.
Medicare and other third-party payers should accept state title certiﬁ-
cation as a prerequisite for reimbursement eligibility. Such certiﬁcation
can and should be based on examinations and other eligibility criteria
the states may establish.

The committee endorses the establishment of sunrise criteria to guide
states’ decisions about whether to regulate health occupations and, if so,
how. These decisions should follow three basic principles:

1. the protection of the public is the sole reason for states to regulate
health occupations;

2. the least restrictive regulatory mechanism consistent with public pro-
tection should be selected, taking into account other means that are in
place; and

3. if, after due deliberation, the decision is made to regulate an occu-
pation, it must be followed by a continuing commitment of resources on
the part of the legislature, the governor, and the relevant administrative
agencies.

256 ALLIED HEALTH SERVICES

State regulatory structures and procedures must be improved if they are
to be effective. In most states the composition of boards, the requirements
for entry, and the ﬂow of information to the public are not fully consistent
with the public interest.

The committee recommends that states strengthen the accountability
and broaden the public base of their regulatory mechanisms. In the near
term, the committee suggests the following:

0 Licensing boards should draw at least half of their membership from
outside the licensed occupation; members should be drawn from the
public as well as from a variety of areas of expertise such as health
administration, economics, consumer affairs, education, and health ser-
vices research.

0 Flexibility in licensure statutes should be maintained to the greatest
extent possible without undue risk of harm to the public. This may mean,
for instance, allowing multiple paths to licensure or overlapping scopes
of practice for some licensed occupations.

The regulatory process should be conducted as openly as possible and
should produce a ﬂow of information to the public, including:

0 the scope of practice of the occupation as defined by state law and
regulation;

0 the eligibility requirements for entry into the occupation;

0 basic information about licensees, including the status of their license
and any disciplinary actions taken by the state, as well as basic data such
as educational background, which should be collected as part of the li-
censing process; and

0 board membership and procedures, especially procedures for ﬁling
complaints against licensed professionals.

Regulatory boards should be well connected to the state bureaucracy.

If a state requires graduation from an accredited educational program
for licensure, the state should take an active interest in the accreditation
requirements to ensure that they are consistent with the state’s interests.

Finally, the committee believes that decisions by states, accrediting bodies,
and health care payers regarding scope of practice, referral, and super-
vision should be better informed. The Bureau of Health Professions (or
another future focal point for allied health personnel in the Department
of Health and Human Services) should sponsor a body with members
drawn from allied health and other health professions and from the health
and social science research communities to assess objectively the evi-
dence bearing on jurisdictional issues. This body, in consultation with
other experts and interested parties, should consider issues of risk, cost,

REGULATING ALLIED HEALTH PERSONNEL 257

quality, and access. It should draw on available scientiﬁc evidence and
identify topics on which research is needed.

Well—designed experiments and demonstrations of innovative roles for
allied health personnel will provide valuable evidence to guide regulatory
policy.

REFERENCES

Accreditation Manual for Hospitals. 1988. Chicago: Joint Commission on Accreditation
of Healthcare Organizations.

American Dental Association. 1987. Testimony before the IOM Committee to Study the
Role of Allied Health Personnel’s Hearing on Regulation. National Academy of Sci-
ences, Washington, DC. July.

American Dental Hygienists’ Association. 1987a. Paper submitted to the IOM Committee
to Study the Role of Allied Health Personnel’s Hearing on Regulation. National Acad-
emy of Sciences. Washington, DC. July.

American Dental Hygienists’ Association. 1987b. Testimony before the IOM Committee
to Study the Role of Allied Health Personnel’s Hearing on Regulation. National Acad-
emy of Sciences, Washington, DC. July.

Begun, J. W. 1981. Professionalism and the Public Interest: Price and Quality in Optom—
etry. Cambridge, Mass: MIT Press.

California Office of Statewide Health Planning and Development. 1987. Health Manpower
Pilot Projects Program: Annual Report to the Legislature and the Healing Arts Li-
censing Boards. Sacramento: State of California Ofﬁce of Statewide Health Planning
and Development.

Carpenter, E. S. 1987. State regulation of allied health personnel trends and emerging
issues. Background paper commissioned by the Institute of Medicine Committee to
Study the Role ofAllied Health Personnel. National Academy of Sciences, Washington,
DC.

Carroll, S. L., and R. J. Gaston. 1977. Occupational Licensing: Final Report. Washington,
DC: National Science Foundation.

Cohen, H. S. 1980. On professional power and conflict of interest: State licensing boards
on trial. Journal of Health Politics, Policy and Law 5(2):291—308.

Committee on Allied Health Education and Accreditation. 1987. Allied Health Education
Directory, 1987. 15th ed. Chicago: American Medical Association.

Gaumer, G. L. 1984. Regulating health professionals: A review of the empirical literature.
Milbank Memorial Fund Quarterly/Health and Society 62(3):?)80—416.

Goldman, S. K., and W. D. Helms. 1983. The regulation of the health professions. A
policy review prepared for the Commission of Health Regulatory Boards of the Com—
monwealth of Virginia. Richmond, Va. October.

Holen, A. S. 1977. The Economics of Dental Licensing. Arlington, Va.: Center for Naval
Analysis.

Institute of Medicine, Committee to Study the Role of Allied Health Personnel. 1987.
Mechanisms for Controlling the Quality of Allied Health Personnel. Public hearing
held on July 1 at the National Academy of Sciences, Washington, DC.

Maurizi, A. 1974. Occupational licensing and the public interest. Journal of Political Econ—
omy 82:399—413.

McCready, L. A. 1982. Emerging health care occupations: The system under siege. HCM
Review (Fall):71—76.

258 ALLIED HEALTH SERVICES

National Advisory Commission on Health Manpower. 1967. A Report by the Committee
on Health Manpower, Vol. 1. Washington, D.C.: Government Printing Ofﬁce.
Shimberg, B. 1982. Occupational Licensing: A Public Perspective. Princeton, NJ; Edu-
cational Testing Service.

Shimberg, B. 1984. The relationship among accreditation, certiﬁcation and licensure.
Federal Bulletin (April):99—115.

US. Department of Health, Education, and Welfare, Ofﬁce of the Assistant Secretary for
Health and Scientiﬁc Affairs. 1971. Report on Licensure and Related Health Personnel
Credentialing. Washington, DC: Government Printing Ofﬁce.

8

Allied Health Personnel and
Long—Term Care

 

EARLIER CHAPTERS or THIS REPORT discussed whether the supply of
allied health personnel will be sufﬁcient to meet the future demand.
This demand has been understood as effective demand, or the number of
allied health practitioners for whose services purchasers would be willing
to pay, given probable economic constraints. In constrast, this chapter shifts
the focus from the number of workers needed to ﬁll jobs to the qualitative
improvements that may be necessary if the allied health labor force is to
be responsive to the needs of a particular segment of our society—those
requiring long-term care. These improvements relate not only to whether
care givers have the right technical skills to offer but also to whether services
are organized and delivered in a way that enhances the quality of life for
long-term care consumers.

Clearly, ﬁnancing policies are a key to quality care, although the available
evidence on nursing homes at least has not shown what the minimum
reimbursement, stafﬁng levels, and staff qualiﬁcations must be to provide
adequate care (Institute of Medicine, 19863). Resolving these ﬁnancial is-
sues is beyond the scope of this study. However, the committee believed
that it could contribute to policy discussions of long-term care reform by
addressing human resource management and educational issues that emerged
during the course of its inquiry. As a means of gaining insight into these
issues the committee supplemented its review of the literature, discussions
with experts, and its own experience with site visits to 11 long-term care
facilities in urban and rural areas of California, North Carolina, and Vir—
ginia. These site visits guided the committee’s selection of the issues it could
reasonably address in the context of its overall report. The collaboration

259

260 ' ALLIED HEALTH SERVICES

of allied health personnel with one another and their interactions with
other health care givers was one recurrent issue. The extent to which allied
health curricula prepare students for long—term care settings was another.

LONG-TERM CARE AND ITS CONSUMERS

Although long—term care is defined in a number of different ways, for
the purposes of this study, it is a broad range of clinical, social, and personal
supportive services for people who need assistance over a sustained period
of time to maintain or improve their well—being. The goal of long-term
care is the maintenance or restoration of the highest possible level of phys-
ical, mental, and social functioning of individuals within the constraints of
their illnesses, disabilities, and environmental settings (Meltzer et al., 1981;
Kane and Kane, 1982).

In emphasizing the many types of services necessary to achieve the high-
est attainable quality of life and personal autonomy, this deﬁnition has two
important implications for those who provide care and for how those care
givers interrelate. First, care givers of many different professions and dis-
ciplines, as well as a patient’s family and friends, must be involved. Second,
this is a process that relies on a ﬂow of information concerning an indi—
vidual’s needs, required services, and potential for recovery.

Long—term care can be provided in institutional settings such as nursing
homes (mostly skilled nursing and intermediate care facilities), institutions
for the mentally retarded, residential care facilities (e.g., board and care
homes), long-stay hospitals (e.g., psychiatric hospitals), specialized schools,
and hospices. It is also provided in ambulatory care settings, in community
day care programs, and through home care services. Some rehabilitation
facilities provide long-term inpatient care but also offer specialized am-
bulatory care over an extended period of time.

Although much of this chapter is about the elderly, others need long-
term care services, including infants with birth defects, developmentally
disabled children, adolescents who have suffered head trauma or spinal
cord injury, laborers with emphysema, and elderly people with multiple
sensory deficits. Also in need of such services are the chronically mentally
ill and the severely retarded. In addition, the AIDS epidemic has focused
attention on the long—term care needs of persons with chronic infectious
diseases.

Because demographic projections suggest that the largest increase in the
need for long-term care will come from the aging population, the service
needs of the elderly have received the most attention of late. Indeed, the
committee’s examination of this topic coincides with the release of two
major reports. The ﬁrst, mandated by Congress, was cochaired by the
directors of the National Institute on Aging and the Bureau of Health

ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 251

Professions in the Health Resources and Services Administration. Their
report examines “the adequacy and availability of personnel prepared to
meet current and projected needs of elderly Americans through the year
2020” (National Institute on Aging, 1987).

A second study was conducted by the National Task Force on Geron-
tology and Geriatric Care Education in Allied Health. Established by the
American Society of Allied Health Professions, the task force explored the
implications of demographic and disease pattern trends for allied health
professional education and practice (National Task Force, 1987).

The two studies reinforce some of the themes developed in this chapter.
An aging population in need of long-term care will increasingly dominate
the practice of most health care workers and will create pressure for greater
numbers of personnel in total. Preparation for this future will require
significant interventions in the way we educate and “socialize” students to
treat patients and work with other health colleagues in the long-term care
environment.

DETERMINANTS OF NEED FOR LONG-TERM CARE

A number of factors~health and functional status, income, living ar-
rangements, marital status—inﬂuence who among us are likely to become
long-term care consumers and the types of services we will receive. A review
of these factors reveals why there is concern about the capacity of the health
care system to meet these future challenges.

0 The need for the formal support of nursing home care increases
sharply with age, as do the effects of chronic disabling disease. The nursing
home utilization rate is 2 percent for persons 65 to 74 years of age, 6
percent for those 75 to 84; and 23 percent for those 85 and older (Rice,
1985).

0 If current morbidity, disability, and functional dependence rates and
patterns continue, by the year 2000 about 50 percent more noninstitutional
elderly people will require the help of others in daily living activities than
required such help in 1980. At the same time, the number needing nursing
homes could increase by 77 percent. In addition to the elderly, it is estimated
that the number of individuals under 65 years of age who are functionally
dependent as a result of chronic disabling disease may well equal that of
those over 65 (Institute of Medicine, 1986b).

0 Marital status inﬂuences the use of long—term care services (especially
nursing homes) because people without spouses may not have anyone to
provide the personal care that would allow them to stay in the community.
In 1985, 84 percent of the elderly in nursing homes were without spouses,
compared with 56 percent of functionally impaired people living in the

262 ALLIED HEALTH SERVICES

community (Macken, 1986; National Center for Health Statistics, 1987b).
If women continue their more rapid (compared with men) mortality im-
provements (Institute of Medicine, 1986b), there will be more unmarried
spouses requiring nursing home care.

0 Infectious disease patients are likely to cause a noticeable increase in
the demand for long-term care and the services provided by allied health
personnel. The number of AIDS patients jumped from 183 in 1981 to
more than 49,000 at the end of 1987 (Centers for Disease Control, 1987a).
The US. Public Health Service estimates that 1.5 million people are already
infected with the AIDS virus (Centers for Disease Control, 1987b). Al-
though relatively small proportions of AIDS patients may need long-term
institutional care (e.g., those with dementia), there are indications that
community care could bring a large demand for home health services
(Braun, 1987; R. Widdus, IOM Committee on a National Strategy for
AIDS, personal communication, 1987; Long-Term Care Management, 1988).

0 More than 250,000 infants are born in the United States each year
with physical or mental defects (March of Dimes, 1987). Despite advances
in prenatal detection of the diseases that cause disability, data from the
Centers for Disease Control show that the incidence of most types of birth
defects remained substantially unchanged during the period 1970—1971
to 1981—1983 (Edmonds and James, 1984).

O For the past 15 years, the level of the severely developmentally disabled
in the US. population has remained steady at approximately 1.6 percent.
However, the type of care that they receive has changed dramatically during
that time. In 1967, many of these individuals lived in large public or private
institutions. Today, there is an increasing demand for relatively small,
community—based facilities. The number of such facilities has grown from
about 4,400 in 1977 to 20,000 in 1986. With these structural changes, some
researchers have detected a substantial increase in staff-to-client ratios that
is likely to continue (Braddock, 1988).

Ideally, an assessment of changing demographic and epidemiological
patterns, such as those described above, should lead to an understanding
of the preventive, curative, and rehabilitative needs of persons who become
elderly or ill. Understanding care requirements clarifies the type of edu-
cation and training programs care givers should have to be able to meet
the needs of patients—which should lead to the development of appro-
priate educational programs.

Unfortunately, this idealized sequence does not occur—for many rea-
sons. Chief among these is the lack of adequate ﬁnancing, which limits who
gets into the formal care system; the amount and quality of services pro—
vided; and the attractiveness of long-term care employment to health care
workers. The scope of this study did not permit an exploration of the

ALLIED HEALTH PERSONNEL AND LONG—TERM CARE 263

broader ﬁnancing problems of long-term care; the committee devoted its
attention to possible educational strategies and human resource manage-
ment interventions in nursing homes, home care, and rehabilitation facil-
ities—three settings in which allied health personnel play vital but different
roles. The committee also explored the problems of integrating allied health
services with those of other care givers in these settings, including aides,
who may collaborate with or at times substitute for allied health personnel.

Nursing Homes

The majority of institutional long-term care is provided in nursing homes.
In 1985, there were 19,100 nursing homes with 1,624,200 beds. These
ﬁgures reﬂect a 22 percent increase in the number of homes and a 38
percent increase in the number of beds since 1974 (National Center for
Health Statistics, 1987a).

Despite the demographic and disease pattern changes described earlier,
the nation’s stock of nursing home beds is not keeping pace with the growth
in demand—let alone the probable need. The result is that nursing homes
usually have high occupancy rates and long waiting lists, thus allowing
operators to select “light” care and private-pay patients. This policy ob-
viously works to the detriment of those who are poor and most in need of
care. Efforts to change this situation are constrained by the states, which
often seek to limit their Medicaid budgets through certiﬁcate-of-need reg-
ulations that control the building of new beds (American Health Care
Associations, 1985, 1986). Future growth will depend on the federal gov-
ernment increasing its funding of long-term care or helping to create
incentives for the small but growing private insurance market.

In 1985 there were approximately 1.2 million FTE nursing home em-
ployees. More than 700,000 provided personal care, of which nurse’s aides
and orderlies were the largest group (71 percent). The number of allied
health professionals providing nursing home care on a salaried basis is
comparatively small: in 1985 there were approximately 7,000 dietitian/
nutritionists, 2,900 registered physical therapists, 2,600 registered medical
record administrators, and 1,500 registered occupational therapist FTE
employees (National Center for Health Statistics, 1987a; G. Strahan, per-
sonal communication, 1987*). Despite efforts to constrain bed growth, BLS
projects that nursing home employment will grow through the year 2000
at an annual rate of 3.8 percent, or about three times the projected growth
for the overall economy (Personik, 1987).

*Personal communication regarding unpublished data from the National Nursing Home
Survey, Division of Health Care Statistics, National Center for Health Statistics.

264 ALLIED HEALTH SERVICES

Nursing Home Residents and the Organization of Care

The typical nursing home resident is an 80—year-old white widow who
has several chronic medical conditions and was admitted to the nursing
home about 1—1/2 years earlier after being a patient in a hospital or other
health care facility. Seventy-ﬁve percent of elderly nursing home residents
in 1985 were women; only 6 percent were black, and less than 1 percent
were of other races. The fact that a higher proportion of the elderly white
population (5 percent) receives nursing home care compared with black
(4 percent) and other races (2 percent) is probably due to the substitution
by nonwhites of informal care in the home for institutionalized care (Na-
tional Center for Health Statistics, 1987b; Macken, 1986).

A patient enters a nursing home by physician referral or by direct ap-
plication of the family. All services must be prescribed by a physician and
furnished according to a written plan initiated by the physician. The care
plan is developed in consultation with the appropriate nursing and allied
health personnel. For example, an occupational therapist assists the phy-
sician by evaluating the patient’s level of functioning, helping to develop
the plan, preparing clinical and progress notes, educating and consulting
with the family and other agency personnel, and participating in in-service
programs. Occupational therapy assistants, under the supervision of a qual-
ified occupational therapist, perform the services that have been planned
and delegated by the therapist. They also help to prepare clinical notes
and progress reports and help educate the patient and family (American
Occupational Therapy Association, 1987).

To be certiﬁed under Medicare’s conditions of participation, nursing
homes must ensure the availability of allied health services. Yet the number
of full-time allied health personnel actually employed there is small because
most nursing homes ﬁnd that reimbursements do not cover many of these
services. To conserve resources, consulting arrangements and part—time
work are the norm for therapists and other allied health workers. When
funds are available to hire allied health personnel, many facilities appear
to have difﬁculty in attracting such staff.

Registered nurses supervise or coordinate the direct care of patients in
nursing homes, and one tool for enhancing communication among care
givers is the team meeting. The regularity of these meetings varies among
facilities. Often headed by nurses, the team may not necessarily include
allied health personnel. Optimally, the meetings should not only provide
an opportunity to exchange information about patients but should also
serve as a way to organize the care that best responds to an individual
patient’s needs.

One approach to incorporating allied health personnel into such a team
effort was described to IOM’s Committee on Nursing Home Regulation.

ALLIED HEALTH PERSONNEL AND LONG—TERM CARE 265

In this model, allied health specialists played a strong educational rather
than direct patient care role:

Each nursing unit has a primary care team composed of the physician, head nurse
and social worker for that unit. The primary care team guides the resident care
planning. All members of the team have an equal voice in this planning. Auxiliary
staff such as physical therapists, occupational therapists, leisure activity specialists,
dietetic technicians, etc., are assigned to each unit and work with the primary care
team. In addition to individual relationships, unit team members plan and assess
resident care in a variety of organized meetings. These types of meetings may have
a different focus. For example, unit clinical meetings focus on residents” psycho-
logical problems, rehabilitation rounds focus on physical therapy. These meetings
have one thing in common, however; they include all care givers including the
nurse aide staff. (Boehner, 1984)

As a practical matter in today’s nursing home environment, the reha-
bilitation services that allied health personnel might be providing directly
are either absent or stretched across a large patient base. The linkage of
allied health expertise to the activities of nurses and aides becomes a critical
element in how well patients can improve their functioning. This linkage
is dependent on opportunities for effective communication between allied
health personnel and the nursing staff, as well as on the ability of other
care givers—aides in particular—to receive and act on the advice of the
allied health practitioner.

Nurse’s Aides

The quality of life for patients is significantly affected by the quality of
care provided by the care givers who have the most frequent contacts with
them—the aides. The typical nurse’s aide is a woman who is about 35 years
old and who has no more than a high school education. She has little or
no training in nursing skills. She has been employed in her current job
less than 2 years and has less than 5 years’ total experience as a paid care
giver (National Center for Health Statistics, 1987b; G. Strahan, personal
communication, 1987). Most aides are white, but a sizable proportion (32
percent) are black or other minorities, which is higher than their repre—
sentation in the labor force as a whole (13 percent) (Kahl, 1987).

On an average day, the aide has a wide range of activities. For example:

The aide is expected to do passive range-of—motion exercises for stroke or paralysis
patients. If hemorrhaging occurs, she must immediately elevate the body and apply
pressure before calling the nurse. She must use correct body mechanics or seek
help in moving patients. The aide is expected to reconcile food service deliveries
with patient's dietary restrictions. She regularly observes changes in patient status
such as whether a patient’s toe nails need to be cut and whether decubiti are present.
She monitors food and water intake, and emotional states. A capable aide would

256 ALLIED HEALTH SERVICES

notice potential circulatory problems, changes in temperature, and paralysis. Aides
also provide clean, wrinkle-free bed linens. They receive and return linens to the
laundry or food trays to the kitchen. Aides are expected to initiate and facilitate
interaction with residents and to assist in and encourage ambulation (Brannon and
Bodnar, 1988).

As the foregoing list ofduties illustrates, aides have major responsibilities
for which they may have little training or experience to prepare them.
There is also little status, recognition, or compensation for this key role.
While most often viewed as part of the nursing staff, the problems aides
encounter are, nonetheless, ones that also concern allied health practition-
ers or that overlap the responsibilities of allied health assistants. For ex-
ample, both nurse’s aides and occupational therapy assistants play a role
in patients’ daily hygiene and rehabilitation exercise programs.

The recent IOM report on nursing home regulation, in relating the
improved functioning of residents to their sense of well-being, noted how
aides shaped the residents’ social world:

. . . 80 to 90 percent of the care is provided by nurse’s aides and the quality of their
interactions with the residents—110w helpful, how friendly, how competent, how
cheerful they are and how much they treat each resident as a person worthy of
dignity and respects—makes a big difference in the quality of a resident’s life.
(Institute of Medicine, 1986a)

Because of their importance to the quality of care provided in nursing
homes, as well as in home care, the levels and content of aide training have
been focuses for reform. It is interesting to note that the recommendation
from the IOM Nursing Home Standards Committee to make aide training
a regulatory standard was one of the few exceptions to an approach that
relied principally on patient outcome measures to ensure quality. Following
IOM’s recommendation, the Health Care Financing Administration pro-
posed a rule to require that aides receive a minimum of 80 hours of training
(Federal Register, 1987). Shortly thereafter, a provision of the Medicare
law requiring 75 hours of aide training was enacted through the Omnibus
Budget Reconciliation Act of 1987.

In many nursing homes, annual turnover is extremely high for aides,
and in some cases, all of the aides may be replaced in the course of a year.
High turnover has been linked to several factors, most important of which
are employee pay and beneﬁts. Aides generally earn only about $10,000
per year (Kahl, 1987). It is not surprising, then, that during site visits the
committee heard reports of aides changing jobs for a 25- to 50-cents per—
hour pay increase.

In addition to turnover, earnings play a part in a growing aide recruit-
ment problem. Earlier chapters in this report noted the general tightness
of the labor market for technically oriented personnel. Similarly, young,

ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 267

low-wage service workers will also be at a premium. Some employers in
the nursing home industry see themselves in direct competition for these
employees with the fast-food industry, for instance, which is beginning to
offer higher starting salaries and the attraction of greater opportunities to
socialize with peer workers in a less onerous atmosphere (Kerschner, 1987).
Because of this competition, there is increasing interest in targeting older
individuals for recruitment. These older workers (who are also being re-
cruited by McDonald’s fast-food restaurants), whose cohort will be ex-
panding in the population in the future, already are a sizable proportion
of the aide-level work force: 40 percent of aides are over the age of 35
(Kahl, 1987).

Pay alone, however, will not solve recruitment, retention, and turnover
problems. Aides’ poor self-perceptions and lack of involvement in the de-
cision-making process regarding their responsibilities will require action by
management (Waxman et al., 1984). The lack of career ladders, work
scheduling, management attitudes, and understafﬁng are other common
frustrations voiced by the aides themselves.

In light of their critical role in patient well-being and rehabilitation, the
questions of how much training aides need to function effectively, how
they relate to others who provide nursing and allied health services, and
what kinds of pay and careers suit their level of responsibility are issues
that nursing home management cannot avoid. If, in the future, there are
to be sufficient numbers of people to carry out the responsibilities that
aides presently assume, the nursing home industry must not only improve
low wages and working conditions but confront the organizational chal-
lenge of deploying staff wisely. Allied health care givers in nursing homes
will necessarily become involved in these issues. Enhanced pay and re-
sponsibility for aides will require that allied health personnel forge new
working relationships and increasingly accept pedagogical roles.

HOME CARE

Home health care, which is often viewed as a substitute for nursing home
placement or extended host talization, shares many of the same generic
problems faced by nursing homes. Agencies ﬁnd it difficult to recruit and
retain staff at the aide level, and teamwork is frequently inadequate among
nursing and allied health personnel. These problems are exacerbated in
home care, which by its very nature requires staff to operate with less direct
supervision.

/

Home Health Care Agencies and Personnel

Although formal community care, such as that provided by home health
care agencies, now accounts for only 15 percent of public long-term care

268 ALLIED HEALTH SERVICES

expenditures, this area has been one of the fastest growing segments of
the health care industry. The number of Medicare—certiﬁed agencies nearly
tripled from 2,212 in 1972 to 6,007 in 1986; the number dropped slightly
to 5,877 in 1987 as agencies reacted to restrictions in Medicare rules. In
1986 there were 105,038 salaried, full—time employees. Registered nurses
were the largest category (34 percent) of personnel, followed by aides (25
percent). About 6 percent of home health care employees were physical
therapists, 2 percent were occupational therapists, and 3 percent were
speech therapists (National Association for Home Care, 1987). Because
some therapists operate on a contract basis or work in agencies that are
not certiﬁed by Medicare, these proportions probably understate the actual
number working in home care. For example, about 22 percent of physical
therapists work at least part of their week for home health care agencies
(American Physical Therapy Association, 1987).

Home health care is not covered by PPS, but since 1985 limitations have
been applied to reimbursement for home health care services. As a result,
many agencies choose not to participate in Medicare and limit their clientele
to private—pay patients. The National Association for Home Care (1987)
has estimated that there were an additional 3,700 agencies in 1987 that
were not certiﬁed for Medicare. Few data are available on recipients or
reimbursement under private insurance. Medicaid can also include home
health care beneﬁts, but payment levels have ﬂuctuated greatly over the
past decade and vary considerably by state. In 1987 New York accounted
for 77 percent of all Medicaid home health expenditures, compared with
California’s 7 percent (Rabin and Stockton, 1987).

Home Health Care Clients and the
Organization of Care

About 80 percent of home health recipients are posthospital referrals.
The typical process of referral from physician to nurse to allied health
personnel can operate smoothly, but it may also mask a set of uneasy
relationships.

The nurse’s View of her role has been characterized by Mundinger (1983):
“When the referral and physician’s plan of care are received by the agency,
an initial nurse assessment visit is made within three days. When the nurse’s
plan is approved, it becomes the operational one for patient care and
replaces the original physician order”:

The plan devised by the nurse includes all of the care to be given as well as
recommendations for referrals. For example, if physiotherapy [sic] is being con-
sidered as care needed, it is the nurse who makes the assessment visit to determine
whether it is in fact really necessary. The nurse decides on the need for a home
health aide. The nurse also can make referrals for other home health services such

ALLIED HEALTH PERSONNEL AND LONG—TERM CARE 269

as occupational therapy, speech therapy, and social worker services. The plan that
is submitted to the physician for signature includes all reimbursable care the nurse
deems necessary. It also includes illness prevention and health maintenance care
required by the patient.

Physicians, as do most professionals, tend to implement the therapies that they
know best, value, and use in their own work. Therefore, home care, traditionally
a low-technology and low-cost venture, under Medicare has become a service ﬁlled
with high-cost care. It is not unusual for a physician to order a battery of expensive
blood tests rather than make a home visit, or utilize physical therapists for routine
range of motion or ambulation of homebound patients. Physicians should be aware
that nurses can teach families to carry out these exercises or that a visiting nurse’s
assessment and history can tell more than blood tests in many cases. (Mundinger,
1983)

The nurse arranges for various services to be delivered separately by
therapists or aides, none of whom may meet with each other as a team.
Such separation of services means that, although important information
can be exchanged through the record, the amount of direct collaboration
for patient problem solving among care givers is often minimal.

Because of this pattern of care, growing attention has been paid to the
issue of who is the care manager, who controls the mix of services, and
how multiple care givers coordinate their services. The care manager (or
case manager) is responsible for ensuring the coordination and continuity
of services (Levine and Fleming, 1986). As the quotation above illustrates,
nurses currently see themselves as fulﬁlling this function. Physicians and
allied health personnel, however, are not necessarily willing to concede this
point.

The following represents the viewpoint of the Health and Public Policy
Committee of the American College of Physicians, which has argued that
physicians ought to be actively involved in assessing the continuing func-
tional as well as medical needs of homebound patients and advising patients
on the use of home health care services:

Although Medicare requires the physician to certify a home health treatment plan,
typically the physician describes the patient’s medical condition to a home health
agency, and a registered nurse actually develops and implements the home care
plan.

Physicians should play an important role in home health care, not only as providers
of medical care, but also as case managers and coordinators of care. Physicians
should assure that their patients continue to receive high-quality medical care after
discharge from a hospital and while receiving treatment in the home.

Unfortunately, the current reimbursement system does not provide any incentives
for physicians to become more involved in home health care. Time spent com-
municating with home health care personnel, devising home treatment plans, com—

270 ALLIED HEALTH SERVICES

pleting certiﬁcation forms, consulting with the patient and family by telephone, or
traveling to a patient’s home is not reimbursable. Indeed, HCFA [Health Care
Financing Administration] maintains that these costs are subsumed in physicians’
payments for ofﬁce visits and home visits. (American College of Physicians, Health
and Public Policy Committee, 1986)

From the perspective of the allied health ﬁelds, the interdisciplinary
group that constitutes the home health care team “is overly dependent
upon a single type of profession, the physician, to write orders.” Patient
needs should determine whether case management is accomplished by an
individual therapist, social worker, nurse, or a team. Yet current reim-
bursement practices, allied health leaders have argued, do not give the
team adequate control over how resources are allocated for the patient’s
care plan (National Task Force, 1987).

Without a reimbursement mechanism that creates incentives for coor-
dinated and appropriate use of the home care services that are potentially
available from a wide array of providers, it will be difﬁcult to overcome
problems of fragmentation, duplication of services, and interprofessional
competition. Short of such a payment scheme, the solutions commonly
cited in the home care and case management literature offer the best hope
for improvement. These include greater use of team conferences, more
complete documentation of patient records, increased attention to deﬁning
the functions of different types of practitioners in home care, more vigorous
case management on the part of home health care agencies, and educational
experiences that prepare students for interdisciplinary collaboration and
case management (Steinhauser, 1984; Trossman, 1984).

REHABILITATION

In moving from a consideration of nursing homes and home care to a
discussion of rehabilitation facilities, a major distinction is soon apparent:
the team approach to clinical management is a well-recognized ﬁxture in
the rehabilitation world. Collaborative behavior among health care prac-
titioners is reinforced by the fact that rehabilitation patients are generally
treated for a functional rather than a medical disability. For Medicare
reimbursement, regulations mandate that patients must receive a minimum
of 3 hours of physical therapy, occupational therapy, speech therapy, or
orthotist and prosthetist services per day for 5 days per week (Medicare
Intmnedz'ary Manual, Section 3101.11 (D)(3), Part A). Intermediary Manual).
The patient who regresses or no longer improves in function must be
discharged into another care environment. The current payment system
places a premium on functional assessment and progression toward im-
proved functioning.

ALLIED HEALTH PERSONNEL AND LONG—TERM CARE 271

There has been significant growth in rehabilitation programs in the last
30 years and a 50 percent growth in the number of rehabilitation beds in
the last 5 years. Today, there are 73 rehabilitation hospitals with 6,225 beds
in the United States. There are also 512 distinct rehabilitation units with
about 13,000 beds in general hospitals. Rehabilitation facilities are currently
exempt from the Medicare prospective payment system because an equi-
table predictor of resource consumption on which to base payment has not
yet been found. (Rehabilitation services in intensive care and in medical-
surgical units of acute care hospitals, however, are not exempt.) Approx-
imately 32 million people are physically disabled, and 12 million people
are severely disabled. The number of severely disabled people has increased
and will continue to increase as the population ages and as technological
advances improve the prospects of children with birth injuries or congenital
defects (England et al., 1987; Lesparre, 1987).

Because patients in rehabilitation settings need specialized and intensive
services, the staff typically includes full—time departments of physical, oc-
cupational, and speech therapy, radiological and laboratory services, and
sometimes respiratory therapy. Social, psychological, and vocational services
are also provided but on a consultant basis. Although the staff in rehabil—
itation hospitals typically work in teams, some experts call for an additional
category of case managers to help ensure appropriate and timely referrals,
reduce admission delays, and assess insurance gaps (England, 1987; Les-
parre, 1987). ‘

By tradition, allied health practitioners, together with nurses, play a
central role in the delivery of team health care. For example, the ratio of
FTE physical therapists to registered nurses is 1:2 in rehabilitation hospitals,
compared with 1:43 in acute care hospitals (American Hospital Association,
1987). A recent survey by the National Association of Rehabilitation Fa-
cilities showed that 65 percent of the total costs in rehabilitation hospitals
were attributable to staff salaries, wages, and fringe benefits. This per-
centage compares with an average of about 57 percent for all hospitals.
The intensive use of physical therapists, occupational therapists, and spe-
cialized nurses results in higher personnel costs in rehabilitation hospitals.
Salary increases of 7 percent a year for physical therapists, 6 percent for
occupational therapists, and 5 percent for nurses since 1985 reflect the
difficulties these hospitals are experiencing in attracting personnel. Com-
petition for these employees has also resulted in growing recruitment costs
and the increased use of contract personnel (National Association of Re-
habilitation Facilities, 1987).

A survey of 43 rehabilitation facilities in California found vacancy rates
of 15.6 percent for physical therapists, 8.6 percent for occupational ther—
apists, and 10.7 percent for speech—language pathologists. Vacancy rates
for physical therapy and occupational therapy assistants exceeded 20 per-

272 ALLIED HEALTH SERVICES

cent. Among the consequences of these stafﬁng problems, 24 percent of
the respondents experienced admission restrictions, 76 percent showed an
impact on outpatient waiting lists, and 58 percent delayed the initiation of
new services or curtailed existing ones (California Association of Rehabil-
itation Facilities, 1987).

Rehabilitation hospitals see themselves as being at a disadvantage in
competing for allied health personnel in tight labor markets. They attribute
their difficulties to students’ lack of exposure to the potential of a career
in rehabilitation, which is perceived to be an arduous, unattractive job,
bringing little recognition. Rehabilitation administrators fear a continuing
diversion of personnel to more attractive practice settings in which patients
are less incapacitated and earnings are higher.

A brief examination of the experience of the Veterans Administration
(VA), a major provider of rehabilitation services in the nation, offers some
insights into the problems often faced by many rehabilitation facilities,
especially the public institutions. Although the VA labors under personnel
and other constraints peculiar to public facilities in recruiting and com-
pensatingaits employees, the implications of personnel shortages and coping
strategies are an instructive preview of what the future could be for all
rehabilitation facilities in the face of widespread shortages.

The VA’s Experience

Interviews with central ofﬁce officials and chiefs of physical therapy and
occupational therapy at a number of VA medical centers revealed a con-
sensus on a number of points. Many of the centers’ recruitment and re—
tention problems are due to competition for these occupations in the
nonfederal sector. The substitution of less qualified care givers was infre-
quent, although health care delivery services were sometimes curtailed as
a result of the shortage. The problem appears to be worsening; patient
loads are increasing while physical therapy and occupational therapy staffs
continue to decrease.

At one medical center in a mid-Atlantic state, half the physical therapy
slots were vacant. Although physical therapy assistants were employed, they
were not used in lieu of licensed physical therapists because they are not
permitted to evaluate patients. The medical center employed six corrective
therapists (a type of rehabilitation personnel used mostly in the VA), but
they were also comparatively limited in the type of care they were permitted
to provide. A corrective therapist was assigned to the unit to assist patients
in walking. In addition, because of a lack of staff, the physical therapy
treatment room in a newly built nursing home care unit remained Closed.
The chief of physical therapy, who carried a full patient load in an effort
to offset the shortage, stated that nonfederal employers in the area were

ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 273

paying $24,000—$28,000 for new graduates while the VA started them at
$18,000. She added that the presumption among many recent graduates
was that, ultimately, they will enter private practice. In her experience, this
differed markedly from the goals and assumptions of physical therapists
in the past, most of whom spent their entire careers employed by medical
facilities.

In another instance, a large medical center in Southern California had
a substantial geriatric patient population, a spinal cord injury unit, and an
extensive orthopedic caseload. The center also employed a number of well-
known specialists in physical therapy. As a result, recent graduates ﬂocked
there for the quality of the training they could receive. Recruitment success
was high and vacancy rates were relatively low, but physical therapists
typically remained there no more than 2 years. Thus, patients were treated
for the most part by young, inexperienced personnel.

At a relatively small southern medical center, administrators cited both
physical therapist and occupational therapist recruitment problems as lim-
iting the number of bedside treatments provided. There were physical
therapy and occupational therapy education programs offered in this city,
but the institution had been unable to recruit graduates before they relo-
cated to other geographic areas where the pay was higher. Because the
department was too small to require a chief of service, the medical center
needed an experienced occupational therapist before it could recruit recent
graduates who would need seasoning.

The lack of occupational therapists in another southern medical center
resulted in slight modiﬁcations of the duties of assistants and such adjust—
ments as program cutbacks and delays in starting new programs. The chief
of occupational therapy stated that nonfederal occupational therapy jobs
in that city paid $4,000—$5,000 more than what the VA paid, and that it
was virtually impossible for the VA to hire experienced therapists. The
situation seems unlikely to improve, as a recent survey found that there
are 54 job openings in occupational therapy in that city.

At a small rural VA medical center in the Northeast, physical therapy
slots have remained vacant for as long as 2 years. In addition to its lack of
salary competitiveness in a region with high demand, this hospital also
believes that its large geriatric population does not offer the variety that
many practitioners seek.

As discussed in Chapter 6 and in the VA case examples, health care
administrators who face personnel shortages have relied on several strat-
egies to handle the deﬁciencies over the short term. These strategies include
extensive use of overtime, service targeting to the patients most likely to
beneﬁt from them, and downward substitution (or cross-substitution) of
allied health personnel to the extent that regulations permit. In the long
run, unless rehabilitation facilities are willing to become reconciled to the

274 ALLIED HEALTH SERVICES

sort of adaptations described in the VA cases, they will have to improve
their capacity to compete for allied health graduates.

The committee believes that the public will neither wish to nor should
accept service compromises in the quality and availability of rehabilitative
care that are due to major shortages in allied health personnel. Current
data and analytic techniques cannot specify the number of personnel needed
beyond those who are likely to be demanded under current reimbursement
and human resource policies and practices. Yet in the committee’s judg—
ment, rehabilitation facilities will not fare well unless the personnel pool
grows substantially along with an increase in the share of those choosing
to engage in this difficult work.

As we have noted throughout this report, salary adjustments are an
inevitable response to this competition. Indeed, the VA has sought ex-
emptions from Congress on salary scales. Along with these adjustments,
however, must come a more careful and sustained rethinking of the services
that are to be provided and of who provides them. The initiatives to do
this will likely come from health care delivery sites that are attempting to
cope with service demands and constrained budgets, but educators should
not distance themselves from this rethinking process. A new relationship
between health care and academic institutions must be forged. Our rec—
ommendations in the next section address the nature of this partnership.

CONCLUSIONS AND RECOMMENDATIONS

In this chapter, the committee has concentrated on three generic human
resource problems that plague the provision of long-term care.

1. Minimally trained personnel are often the primary patient care givers,
especially in nursing homes and home care. As a result, there is too little
attention to the linkage between nursing and allied health services in the
hands—on care activities of aides.

2. Current efforts to incorporate the care of the aged and chronically
disabled into the allied health curriculum are inadequate in view of the
important impact these patients will have on the health care delivery system
of the future.

3. Collaborative behavior among allied health practitioners, as well as
between allied health practitioners and other health care workers, is in-
sufficiently promoted by management in nursing homes and home care
agencies and by educational institutions in the educational experiences
provided to students.

ALLIED HEALTH PERSONNEL AND LONG—TERM CARE 275

Education of Nurse’s Aides

The passage of the provision in the Omnibus Budget Reconciliation Act
of 1987 requiring a minimum of 75 hours of initial aide training should
mark the beginning of a long—range educational effort. The act speciﬁes
that the content of nurse’s aide training is to include basic nursing skills;
personal care skills; cognitive, behavioral, and social care; basic restorative
services; and residents’ rights (US. Congress, House of Representatives,
1987).

The committee views this training requirement as a reasonable starting
point to raise the skills and knowledge of entry-level workers who provide
most of the direct patient care in long-term care facilities There is also an
urgent need, however, for a visible pathway leading to higher levels of
education for aides who wish career progression and improved remuner-
ation. Such a pathway into nursing or allied health ﬁelds would contribute
to raising the morale and self-image of these workers and ultimately reduce
the costly turnover of personnel.

In recognition that the greatest amount of direct patient contact and
care in long-term care settings and programs is provided by personnel
at the nurse’s aide level, the federal government and other responsible
governmental agencies should require education and training to raise the
knowledge and skill levels of these individuals. Demonstration projects
should be funded to encourage joint efforts by educators and employers
in creating viable career paths for aides.

Tolerance of and empathy with old, chronically ill, disabled, or demented
patients is an elusive but critical attribute to be sought among care givers.
Without this attribute, individuals are not likely to choose work in long—
term settings as a career. Long-term care employers and educators should
identify and nurture those with this “people—oriented” attribute. One ap-
proach might be for employers and educators to develop local plans in
which service in long-term care settings would earn employer’paid edu-
cational credits that could be used by personnel to further their educational
objectives. Such an investment would yield at least three desirable results:
(1) an improved quality of care for patients; (2) the enhanced recruitment
of minorities, young people, and minimally educated individuals; and
(3) increased stability in the segment of the labor force that provides direct
care. This approach would be particularly attractive if educational pro—
grams in the established allied health professions would reserve a small
proportion of their entry positions (e.g., 10 percent) for applicants from
such long-term care settings.

Other innovative programs that could be jointly sponsored by academic
institutions (e.g., community colleges) and employers should also be con-
sidered in creating a career path. The committee was impressed with the

276 ALLIED HEALTH SERVICES

concept of an apprenticeship model, which has had some success in the
skilled trades but which has not received the attention it perhaps deserves
in the health care ﬁelds. The model stresses on-the-job, practical experience
combined with formal training. A key element in its success is that the
student-worker’s prospects for a “good job” in terms of pay and respon-
sibility should be rewarded at the end of the program. These good jobs,
while not plentiful in today’s long-term care industry, must be developed
in the decade ahead if the industry expects to compete in tomorrow’s labor
market and improve the quality of service it provides.

Enhancing the Curriculum

Although allied health students gain technical expertise in particular
areas of concentration during their education, many have only limited
exposure to chronically ill and disabled persons. They may therefore have
only a superﬁcial understanding of the complexity of the physical, mental,
emotional, and social problems of impaired persons and their families.
When in training, allied health students may not rotate through long-term
care facilities or programs to experience personally the technical difficulties
that arise in evaluating and caring for older or chronically disabled persons.

The committee recommends that all allied health education and train-
ing programs include substantive content and practical clinical experi-
ence in the care of the chronically ill and aged. In general, such curricula
should include information on the demographic shifts and changing epi-
demiological patterns of diseases and disabilities, the biological and psy-
chological aspects of chronic illness and aging, the common medical problems
seen in patients, legal and ethical dilemmas, the medical and psychological
aspects of death and dying, health promotion and disease and disability
prevention, interdisciplinary team participation, the evaluation and assess-
ment of patients’ needs, the roles of related health professionals, admin-
istrative and management techniques, and communication and supervisory
skills.

Among these topics, the committee was particularly impressed during
its site visits by the need for assessment, pedagogical, and coping skills.
Because of shortages or the uneven distribution of allied health profes-
sionals, a member of each allied health speciality may not be available to
make an assessment of a patient from his or her own disciplinary per-
spective. Therefore, it is important that all professional care providers
acquire enough knowledge to enable them to make physical, psychological,
and environmental assessments of an individual patient and to develop an
appropriate care plan. The providers need this broader knowledge even
though some of the patient’s needs may be outside the narrow area of
expertise of a given allied health profession. Because allied health practi-

ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 277

tioners may be employed as consultants with responsibility for a large
number of patients or residents, they must also have the skills to instruct
aides and family members in care plan activities and be able to monitor
the effectiveness and quality of the assistance given to patients.

A major barrier to curriculum reform is the shortage of faculty who are
appropriately trained and experienced in the care of the chronically ill and
disabled. In an effort to combat deﬁciencies in the training of personnel
and faculty, the Health Resources and Services Administration established
regional resource centers through its Geriatric Education Centers program.
The program, which began in 1983, supports the multidisciplinary training
of medical, dental, osteopathic, optometric, pharmacy, pediatric, nursing,
and allied health students, faculty, and others in geriatric health care. Other
governmental programs that have provided multidisciplinary training in—
clude special project grants and the Area Health Education Centers (also
sponsored by HRSA), Long-Term Care Gerontology Centers (sponsored
by the Administration on Aging), and VA’s Geriatric Research, Education,
and Clinical Centers. Despite these programs the National Institute on
Aging task force estimates that the current number of faculty members
specializing in aging and geriatric care ranges from 5 to 25 percent of the
total number needed (National Institute on Aging, 1987). A major focus
for the faculty development grants recommended in Chapter 5 should be
the encouragement of more faculty specializing in geriatric care.

Orienting allied health education toward geriatric care will not make
salaries more competitive or improve working conditions; neither will it
change the fact that such patient care is physically and emotionally difﬁcult.
The committee believes, however, that education in geriatric care will help
those who do choose work in these settings to remain longer by giving
them the necessary knowledge and coping skills. It will also allow more
students the opportunity to consider the possible rewards of such a career
and will encourage more faculty to engage in health services and clinical
research that is relevant to the problems faced by long-term care providers.

Improved Teamwork

The committee noted that the collaborative behavior seen among re-
habilitation hospital staff is frequently absent in nursing homes and home
care. In the absence of financing incentives that encourage teamwork, the
responsibility rests with managers to organize their personnel in ways that
maximize interaction among allied health practitioners and other care giv-
ers. The committee therefore recommends that because the problems
associated with chronic illness do not fall within the boundaries of any
single discipline, administrators and care coordinators in long-term care
settings should develop effective means for ensuring that all personnel
involved in patient care work closely together to meet patient needs.

278 ALLIED HEALTH SERVICES

Health care managers would be greatly helped in these endeavors if
educators provided the foundation on which to build collaborative behavior
in later practice. Allied health practitioners need to understand and ap-
preciate the special skills and roles that their fellow allied health workers
play, together with the assets and limitations of others on the long-term
care team.

The issues of recruitment, education, personnel utilization, and regu-
lation that have been raised throughout this report take on a special sig-
niﬁcance in the nation’s struggle to achieve humane care for its growing
numbers of elderly and chronically ill patients. Society will be under great
pressure to accommodate larger numbers of patients in the settings dis-
cussed here. It will also be under at least as great a pressure to limit the
resources that may be necessary to raise the standard of care. Allied health
practitioners who are caught up in this struggle will be challenged to use
their ingenuity—both on a personal level, as care providers, and collectively,
as an important force for reshaping the care system.

The remedies suggested in this chapter are not new: they can be found
in the work of current committees and task forces and even in past Institute
of Medicine studies on nursing and health care teams (Institute of Medicine,
1972, 1983). But the time to move teamwork and geriatric education ahead
is long past due.

No single recommendation the committee can devise will accomplish this
movement. It must come from leaders in the health professions who are
willing to concede a measure of control and autonomy in favor of the
common goal of collaborative patient care. It will require the ingenuity of
educators in seeking additional resources for curriculum reform. It will
also demand the resolve to initiate a painful process of resource allocation
that places a higher value on care giver collaboration and preparation for
the demands of long-term care.

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American Health Care Association. 1986. Nursing Homes, A Sourcebook. Washington,
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American Hospital Association. 1987. Unpublished data from the Annual Hospital Survey
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American Occupational Therapy Association. 1987. American Occupational Therapy.
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American Physical Therapy Association. 1987. Active Membership Proﬁle Study. Alex-
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ALLIED HEALTH PERSONNEL AND LONG-TERM CARE 279

Boehner, E. M. 1984. Managing to achieve quality of life. Background paper prepared
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Brannon, D., and J. Bodner, 1988. The Primary Care Givers: Aides and LPNs. Mental
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California Association of Rehabilitation Facilities. 1987. Survey on rehabilitation man-
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Centers for Disease Control. 1987a. AIDS Weekly Surveillance Report—United States,
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Centers for Disease Control. 1987b. Human Immunodeﬁciency Virus Infections in the
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Edmonds, L., and L. James. 1984. Temporal trends in the incidence of malformation in
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APPENDIXES

APPENDIX

 

Congressional Mandate:
Study of the Role of

Allied Health Personnel in

Sec. 223
(a) (1)

Health Care Delivery>l<

The Secretary of Health and Human Services shall arrange
for the conduct of a study concerning the role of allied health
personnel in health care delivery. The Secretary shall request
the National Academy of Sciences to conduct the study under
an arrangement under which the actual expenses incurred by
the Academy in conducting such study will be paid by the
Secretary and the Academy will prepare the report required
by subsection (c). If the National Academy of Sciences is willing
to do so, the Secretary shall enter into such an arrangement
with the Academy for the conduct of the study.

If the National Academy of Sciences is unwilling to conduct
the study required by paragraph ( 1) under the type of ar-
rangement described in such paragraph, the Secretary shall
enter into a similar arrangement with one or more appropriate
nonprofit private entities.

(b) The study required by subsection (a) shall:
(1) assess the role of allied health personnel in health care delivery;

(2)

(3)

identify projected needs, availability, and requirements of var-
ious types of health care delivery systems for each type of allied
health personnel;

investigate current practices under which each type of allied
health personnel obtain licenses, credentials and accreditation;

*Public Law 99-129, signed October 22, 1985.

283

284 APPENDIX A

(4) assess changes in programs and curricula for the education of
allied health personnel and in the delivery of services by such
personnel which are necessary to meet the needs and require-
ments identiﬁed pursuant to paragraph (2); and

(5) assess the role of the Federal, State, and local governments,
educational institutions and health care facilities in meeting the
needs and requirements identiﬁed pursuant to paragraph (2).

(c) By October 1, 1987, the Secretary of Health and Human Services
shall transmit to the Committee on Labor and Human Resources of the
Senate and the Committee on Energy and Commerce of the House of
Representatives, and make available to the public, a report:

(1) describing the study conducted under this section;

(2) containing a statement of the data obtained under such study;
and,

(3) specifying such recommendations for legislation and admin-
istrative action as the Secretary considers appropriate.

APPENDIX

 

Participants in Workshops and
Public Meetings

COMMITTEE PUBLIC MEETING HELD JULY 1, 1987

American Association for Marriage and Family Therapy
MICHAEL BOWERS

American Association for Respiratory Care
MEL MARTIN, President

American Association of Bioanalysts
DON LAVANTY, Government Relations

American Association of Certiﬁed Allied Health Personnel in
Ophthalmology
NORMA GARBER
ELLA ROSAMONT—MORGAN

American Association of Certiﬁed Orthoptists
BARBARA CHASSIN
RANDY GOUTERMAN

American Association of Medical Assistants, Inc.
DON BALASA, Assistant Director

American Cardiology Technologists Association
STEPHEN KANIECKI, President
LINDA HUMSTON

American College of Cardiology
FRANCIS]. MENAPACE, jR.

American College of Nurse-Midwives
KAREN BODENHORN

285

286 APPENDIX B

American College of Radiology
ROBERT BRADEN
MARK MISHKIN, Committee on Human Relations
MARIE ZINNINGER
American College of Surgeons
CINDY BROWN, Washington Associate
American Dental Association
BRENDA HARRISON, Director, State Government Affairs
]. O’DONNELL, Director, Legislative Policy
L. P. WHEAT, Director, Government Relations
LOUIS SCHUHRKE, Council on Dental Education
American Dental Hygienists Association
DIANE DE Roos BASSAGE, Second Vice—President
WILLIAM SCHMIDT
American Dietetic Association
PATTI BLUMER
BOB EARL, Manager, Government Affairs
jEAN MINSKOFF
American Hospital Association
BARBARA KREML, Director, Human Relations
American Medical Record Association
RITA FINNEGAN, Executive Director
American Medical Technologists
ELEANOR BORS, Executive Director
WILLIAM ROBBINS, Member, Board of Directors
American Occupational Therapy Association
jEANETTE BAIR, Director, Practice
STEPHANIE HOOVER
SUSAN SCOTT, Director of Government and Legal Affairs
American Orthotic and Prosthetic Association
WILSON LATKOVIC, Assistant Director
GEN. WILLIAM MCCULLOCH, President
CHARLES UNGER
American Physical Therapy Association
FRANK MALLON, Associate Executive Vice-President, Professional
Relations
TOM WELSH, Chief, Physical Therapy
American Society for Medical Technology
SIDNEY OLIVER '
LYNN PODELL, Executive Director
GLENDA PRICE
American Society for Parenteral and Enteral Nutrition
JANET GANNON, Director of Professional Development

APPENDIX B 287

American Society of Allied Health Professions
DAVID BROSKI
PAT GILLESPIE
American Society of Clinical Pathologists
BARBARA CASTLEBERRY, Vice—President
PAUL CHERNEY, Chairman, ASCP Board of Registry
CATHY COHEN
BOBBI-LYNN WATNIK, Legislative Assistant
American Society of Cytology
SALLY-BETH BUCKNER
ANN H. CLARK
American Society of Electroneurodiagnostic Technologists
LEIGH O’NEAL, Member, Board of Trustees
American Society of Microbiology
DIETER GROESCHEL, Chairman, Committee on Laboratory Practices
for Microbiology
American Speech—Language—Hearing Association
MORGAN DOWNEY
jAMEs LINGWALL
Association of Surgical Technologists, Inc.
BARBARA GAY
WILLIAM TEUTSCH
Bureau of Labor Statistics, US. Department of Labor
ANN KAHL, Economist
Congressional Research Service
jANET KLINE, Chief, Health Section
Gini Associates
EUGENIA CARPENTER, President
Greater Southeast Community Hospital
THOMAS CHAPMAN, President
MICHELE JOHNSON, Administrative Fellow
Health Care Financing Administration, US. Department of Health
and Human Services
STANLEY E. EDINGER, Science Director
Health Resources and Services Administration, US Department of
Health and Human Services
JERRY MCCLENDON
National Board of Cardiovascular Testing, Inc.
DIANA GUNTHER
CAROL ROBBINS
National Coalition for Arts Therapy Associations
jAMEs MITCHELL, Director

288 APPENDIX B

National Commission for Health Certiﬁcation Agencies
BARBARA HICKEY

National Hearing Aid Society
TIMOTHY WATERS, Attorney

National Society for Cardiopulmonary Technology
MICHAEL R. BOIVIN

National Society of Allied Health
HARLEY F LACK, President

Ofﬁce of the Assistant Secretary for Health, US Department of
Health and Human Services
CAROL ZUCKET, Senior Program Analyst

Ofﬁce of the Assistant Secretary for Planning and Evaluation, US.
Department of Health and Human Services
HERBERT C. HAMMOND, Policy Analyst

Society of Nuclear Medicine, Technologist Section
MARCIA BOYD, President
PAUL COLE
VIRGINIA PAPPAS, Deputy Executive Director

Virginia Citizens Consumer Council
HELEN SAVAGE

Virginia Department of Health Regulatory Boards
RICHARD MORRISON

WORKSHOP ON FACTORS THAT AFFECT THE DEMAND FOR
ALLIED HEALTH PERSONNEL
HELD APRIL 26—27, 1987

RONNI CHERNOFF, Associate Director of Geriatric Research, Education and
Clinical Center for Education and Evaluation, Veterans
Administration Medical Center, Little Rock, Arkansas

BRENT ENGLAND, Director, Section for Rehabilitation Hospitals and
Programs, American Hospital Association

NORMAN F. ESTRIN, Vice President, Science and Technology, Health
Industry Manufacturers Association

CHERLYN S. GRANROSE, Assistant Professor, Department of Human
Resources Administration, Temple University

MARTHA HOPLER, Director of Human Resources, Medlantic Health Care
Group

CHARLES HOSTETTER, Deputy Director, AIDS Services Program, Health
Resources and Services Administration

DONALD JACKSON, President, Rehabilitation Systems of Illinois

STANLEY B. JONES, Vice President, Consolidated Health Care, Inc.

APPENDIX B 289

LAIRD MILLER, Health Systems Management

SEYMOUR PERRY, Professor of Medicine and Deputy Director, The Institute
for Health Policy Analysis, Georgetown University Medical Center

RICHARD SCHMIDT, Scanlon, Hastings and Schmidt

DENNIS]. TREAT, Director, Washington, DC, Group Operations, The
Prudential Life Insurance Company of America

KEITH WEIKEL, Executive Vice President, Health Care and Retirement
Corporation of America

COMMITTEE MEETING OF AUGUST 31—SEPTEMBER 2, 1987
List of Participants

TEXAS

jOHN BRUHN, Dean, School of Allied Health, University of Texas
Medical Branch, Galveston

YVONNE NEWMAN, Director, Health Affairs Division, Texas Higher
Education Coordinating Board

PAUL RAMIREZ, Dean, Health and Public Services Occupations, El Paso
Community College

LEO SELKER, Assistant to President, Texas Women’s University

ILLINOIS

DAVID BROSKI, Dean, College of Associated Health Professions

RODERICK T. GROVES, Chancellor, Illinois Board of Regents

ARCH LUGENBEEL, Dean, Trident Technical College, Charleston, South
Carolina (formerly at Southern Illinois University)

RICHARD TWOREK, Dean, Health Services Institute, City Colleges of
Chicago

ROBERT A. WALLHAUS, Deputy Director for Academic Aﬂairs, Board of
Higher Education

NEW YORK

RUTH BAINES, State University of New York, Albany

EDMUND MCTERNAN, Dean, State University of New York, Stony Brook

EDWARD SALSBERG, Director, Bureau of Health Resources Development,
New York State Health Department

LEROY SPARKS, New York City Technical College, Brooklyn

290 APPENDIX B
Additional Participants

TULLIO ALBER’I‘INI, Health Resources and Services Administration,
US. Department of Health and Human Services

CATHERINE B. jUNGE, US. Department of Education

GERRY KAMINSKI, Dean, Health Technologies Division, Cincinnati
Technical College

APPENDIX

 

A Sample of Allied Health
Job Titles and a Classification of

Instructional Programs in
Allied Health

ALLIED HEALTH JOB TITLES*

Clinical Laboratory Technology

Associate Laboratory Laboratory Microbiologist
Microbiologist Laboratory Technician
Chemist (Biochemistry) Principal Microbiologist

Laboratory Associate

Dental Services

Dental Assistant Dental Hygienist

Dietetic Services

Assistant Director of Food Chief Dietitian
Service Dietary Aide
Associate Supervising Dietitian Dietitian

Emergency Medical Services

Ambulance Technician Emergency Medical Service
Ambulatory Care Technician Specialist

*The job titles were taken from the New York City Health and Hospital Corporation.

291

292

APPENDIX C

Medical Record Services

Assistant Director of Medical
Record

Assistant Director, Medical
Record Service

Associate Medical Record
Specialist

Medical Record Specialist
Senior Medical Record Systems
Analyst

Occupational Therapy—Occupational Therapist

Physical Therapy—Physical Therapist

Radiological Services

Nuclear Medicine Technician

Radiation Technician

Respiratory Therapy

Respiratory Therapist

Respiratory Therapy Technician

Speech-Language Pathology/Audiology

Audiology Clinician
Speech Clinician

Staff Audiologist
Staff Speech Pathologist

Other

Addiction Counselor

Addiction Specialist

Assistant Addiction Counselor

Assistant Bio—Medical Equipment
Technician

Assistant Community Liaison
Worker

Assistant Supervisor of
Recreation

Bio-Medical Equipment
Technician

Electrocardiograph Technician

Electroencephalograph
Technician

Medical Equipment Specialist

Operating Room Technician

Orthoptist

Physician Assistant

Psychiatric Social Health
Technician

Rehabilitation Counselor

Rehabilitation Technician

Senior Electrocardiograph
Technician

APPENDIX C 293

A CLASSIFICATION OF INSTRUCTIONAL PROGRAMS
IN ALLIED HEALTH

The Classiﬁcation of Instructional Programs (CIP), developed by the
US. Department of Education’s Center for Educational Statistics (CBS) in
1979—1980, was updated for the ﬁrst time in 1985. CIP is a taxonomy for
instructional programs at all levels. It is used in all CES surveys and is the
accepted government standard for education information surveys.

17. Allied Health

I 7.01 Dental Services

17.0101 Dental Assisting

17.0102 Dental Hygiene

17.0103 Dental Laboratory Technology
17.0199 Dental Services, Other

17.02 Diagnostic and Treatment Services

17.0201 Cardiovascular Technology

17.0202 Dialysis Technology

17.0203 Electrocardiograph Technology

17.0204 Electroencephalograph Technology

17.0205 Emergency Medical Technology—Ambulance
17.0206 Emergency Medical Technology—Paramedic
17.0207 Medical Radiation Dosimetry

17.0208 Nuclear Medical Technology

17.0209 Radiologic (Medical) Technology

17.0210 Respiratory Therapy Technology

17.021 1 Surgical Technology

17.0212 Diagnostic Medical Sonography

17.0299 Diagnostic and Treatment Services, Other

17.03 Medical Laboratoiy Technologies

17.0301 Blood Bank Technology
17.0302 Chemistry Technology
17.0303 Clinical Animal Technology
17.0304 Clinical Laboratory Aide
17.0305 Clinical Laboratory Assisting
17.0306 Cytotechnology

17.0307 Hematology Technology
17.0308 Histologic Technology

294 APPENDIX c

17.0309 Medical Laboratory Technology

17.0310 Medical Technology

17.0311 Microbiology Technology

17.0399 Medical Laboratory Technologies, Other

1 7.04 Mental Health/Human Services

17.0401 Alcohol/Drug Abuse Specialty

17.0402 Community Health Work

17.0404 Home Health Aide

17.0405 Mental Health/Human Services Assisting
17.0406 Mental Health/Human Services Technology
17.0407 Rehabilitation Counseling

17.0408 Therapeutic Child Care Work

17.0409 Population and Family Planning

17.0410 Sign Language Interpreting

17.0499 Mental Health/Human Services, Other

I 7.05 Miscellaneous Allied Health Services

17.0502 Central Supply Technology
17.0503 Medical Assisting

17.0504 Medical Illustrating

17.0505 Medical Ofﬁce Management
17.0506 Medical Records Technology
17.0507 Pharmacy Assisting

17.0508 Physician Assisting

17.0510 Podiatric Assisting

17.0512 Veterinarian Assisting
17.0513 Health Unit Coordinating
17.0514 Chiropractic Assisting
17.0599 Miscellaneous Allied Health Services, Other

17.06 Nursing—Related Services

17.0601 Geriatric Aide

17.0602 Nursing Assisting

17.0605 Practical Nursing

17.0606 Health Unit Management
17.0699 Nursing-Related Services, Other

17.07 Ophthalmic Services

17.0701 Ophthalmic Dispensing
17.0705 Optometric Technology
17.0799 Ophthalmic Services, Other

APPENDIX C

295

17.08 Rehabilitation Services

17.0801
17.0802
17.0803
17.0804
17.0806
17.0807
17.0808
17.0809
17.0811
17.0812
17.0813
17.0814
17.0815
17.0816
17.0817
17.0818
17.0819
17.0820
17.0822
17.0899

Art Therapy

Corrective Therapy

Dance Therapy

Exercise Physiology

Music Therapy

Occupational Therapy
Occupational Therapy Assisting
Occupational Therapy Aide
Orthotics/Prosthetics
Orthopedic Assisting

Physical Therapy

Physical Therapy Aide
Physical Therapy Assisting
Recreational Therapy
Recreation Therapy Assisting
Respiratory Therapy
Respiratory Therapy Assisting
Speech/Hearing Therapy Aide
Recreational Therapy Aide
Rehabilitation Services, Other

I 7.99 Allied Health, Other

17.9999

Allied Health, Other

APPENDIX

 

Estimates of the Current
Supply of Personnel in 10 Allied
Health Fields

Making an accurate assessment of the supply of allied health practitioners
in each of the various ﬁelds is not easy. For many occupations, there is no
reliable data source for either the total number of qualiﬁed people, the
number working, or the number not working but available if the right
market conditions were to occur. BLS uses the Occupational Employment
Survey (OES) to collect data on the number of ﬁlled jobs. In ﬁelds with a
high incidence of persons holding multiple jobs, however, BLS data are
an inaccurate reﬂection of the labor force. Another major source of data
is the decennial census of the United States, which was last conducted in
1980. These data are now dated, and their deﬁnitions of allied health ﬁelds
often do not match the professions’ deﬁnitions. A third source of data,
memberships of the allied health professional associations, may provide
information from only a small fraction of the supply of practitioners. Be—
cause not all practitioners in a ﬁeld are listed as certiﬁcate, license, or
registration holders and not all listed practitioners are in the active labor
force, using these categories as a data source does not always offer accurate
representations of the labor force.

Despite these data limitations, some estimates of the supply of practi-
tioners can be made. For example, in ﬁelds in which holding multiple jobs
is not common, the BLS data closely approximate the number of people
working in the ﬁeld. In addition, professional associations collect data on
both the number of qualiﬁed practitioners and the number of practitioners
active in the ﬁeld. This appendix presents supply estimates that have been
derived from various sources of data. Although it is difﬁcult to pinpoint
a “best ﬁgure,” the estimates can be used to map a reasonable range of the

296

APPENDIX D 297

number of people working in each of the 10 ﬁelds highlighted in this
report.

Dietitians

BLS estimated total dietitian employment in 1986 to be 40,201 positions
(38,201 people held wage and salary jobs, and 2,000 people were self—
employed dietitians). BLS deﬁnes dietitians as people who “organize, plan,
and conduct food service or nutritional programs to assist in [the] pro-
motion of health and control of disease.” Dietitians “may administer activ-
ities of a department providing quantity food service” and “may plan,
organize, and conduct programs in nutritional research.”

The American Hospital Association’s 1985 annual survey indicated that
there were 14,993 full- and part-time dietitians employed in US. registered
hospitals that year. BLS estimates that 37 percent of all dietitians were
employed in hospitals in 1986. Assuming that the number of dietitians
working in hospitals did not change signiﬁcantly between 1985 and 1986,
and that the number in 1986 was roughly equal to the association’s 1985
survey ﬁgure, we can then extrapolate from the American Hospital As-
sociation data (14,933 dietitians employed/37 percent of dietitians) and
estimate that there were about 40,100 dietitians employed in 1986*a ﬁgure
that conﬁrms the BLS estimate.

The American Dietetic Association reported 44,570 registered active
dietitians on its rolls at the end of 1987.

Dental Hygienists

The Occupational Employment Survey deﬁnes dental hygienists as peo-
ple who “perform dental prophylactic treatments and instruct groups and
individuals in the care of the teeth and mouth.” BLS estimated that dental
hygienists ﬁlled 86,676 jobs in 1987—none was self—employed. As men-
tioned earlier, the BLS data pertain to jobs. People who hold more than
one job are counted at each job site. Because the practice of holding multiple
jobs is common among dental hygienists, the number of dental hygienist
jobs that are ﬁlled greatly exceeds the number of working dental hygienists.

The Bureau of Health Professions of the Health Resources and Services
Administration estimate that there were 45,800 dental hygienists in 1984
ﬁlling an estimated 76,000 jobs. Thus, each working hygienist ﬁlled an
average of 1.66 jobs. Assuming the job-to-hygienist ratio was about the
same in 1986 as in 1984, the committee estimates that there were about
52,200 working hygienists in 1986.

Dental hygienists are licensed in every state and the District of Columbia.
To obtain a license, a candidate must graduate from a dental hygiene school

298 APPENDIX D

accredited by the Commission on Dental Accreditation and pass both writ-
ten and clinical examinations. According to the commission’s 1986/ 1987
annual report, a total of 51,713 students graduated from accredited schools
between 1976 and 1986.

Emergency Medical Technicians

BLS estimates that there were 65,229 paid emergency medical techni-
cians (EMTs) in 1986. According to the OES instrument, EMTs “administer
ﬁrst aid treatment and transport sick or injured persons to medical facilities,
working as a member of an emergency medical team.” EMTs are not
ambulance attendants and drivers. ,

Because there are many volunteer EMTs, the number of paid EMTs
understates the true supply of practitioners. The 1985 National Emergency
Medical Services Clearinghouse survey indicated that approximately 95,000
EMTs are certiﬁed annually in 42 states. However, New York, Texas, and
California, three of the most populous states, were not among those re-
porting. Certiﬁcation is generally valid for 2 years; the committee therefore
estimates that there are at least 200,000 certiﬁed EMTs in the United States
in any given year.

Medical Laboratory Technologists and Technicians

According to BLS estimates, there were 239,350 jobs for medical labo-
ratory technologists and technicians in 1986 (this ﬁgure includes 1,000 self-
employed persons). The OES deﬁnes medical and clinical laboratory tech-
nologists as people who “perform a wide range of complex procedures in
the general areas of the clinical laboratory or [who] perform specialized
procedures in such areas as cytology, histology, and microbiology.” Their
“duties may include supervising and coordinating activities of workers en--
gaged in laboratory testing and include workers who teach medical tech-
nology when teaching is not their primary activity.” Medical and clinical
laboratory technicians are deﬁned as persons who “perform routine tests
in medical laboratories for use in treatment and diagnosis of disease.” They
“prepare vaccines, biologicals, and serums for prevention of disease” and
“prepare tissue samples for pathologists, take blood samples, and execute
such laboratory tests as urinalysis and blood counts.” Laboratory technicians
“may work under the general supervision of a medical laboratory tech-
nologist.” Although BLS collects separate data for the two categories of
laboratory personnel, the data are combined for reporting purposes.

It is difﬁcult to estimate the ratio of technologists to technicians. Of the
209,000 registrants of the American Society of Clinical Pathologists in 1987,
82 percent were medical technologists. In September 1987 the registry of
the National Certiﬁcation Agency for Medical Laboratory Personnel was

APPENDIX D 299

composed of 83 percent technologists and 17 percent technicians. If the
above ratios are applied to the BLS estimate of total employment of medical
laboratory technologists and technicians, the numbers of technologists and
technicians 1n the work force in 1986 would have been about 196,267 and
43,083, respectively. A word of caution is in order, however. lechnicians
may be less likely than technologists to be certified; thus, our estimate may
underrepresent technicians and overrepresent technologists. Unfortu—
nately, there is no easy way to verify the ratio of technicians to technologists.

Medical Record Administrators and Technicians

BLS does not estimate total employment for medical record administra-
tors.

The American Hospital Association’s 1985 annual survey shows 7,639
full- and part-time medical record administrators employed in US. reg-
istered hospitals in that year. If, as indicated by the American Medical
Record Association 1986 membership survey, approximately 73 percent
of all medical record administrators work in acute care facilities, we can
extrapolate from the American Hospital Association data to determine the
total number of persons employed as medical record administrators: 10,464.
If this is the case, more than 20 percent of people filling medical record
administrator jobs must be unregistered because the American Medical
Record Association reported only 8,240 registered medical record admin—
istators in 1987.

Medical record technician employment was estimated by BLS to be 39,888
in 1986. The OES deﬁnes medical record technicians as persons who “com—
pile and maintain medical records of hospital and clinic patients.” The
American Medical Record Association reported 14,690 accredited record
technicians in 1987.

The American Hospital Association’s 1985 annual survey shows 43,383
full- and part-time medical record technicians employed in US. registered
hospitals. This ﬁgure is not only substantially higher than the BLS estimate
of 24,500 jobs in hospitals, but it is also higher than the BLS estimate of
total technicians’ jobs in all settings. The reasons for this difference are not
known, but they may be sought in an examination of the ways in which
job deﬁnitions are developed and then interpreted by survey respondents.

Occupational Therapists

BLS estimates that there were 29,355 jobs for occupational therapists in
1985. The CBS deﬁnes occupational therapists as persons who “plan, or-
ganize, and participate in medically oriented occupational programs in
hospitals or similar institutions to rehabilitate patients who are physically
or mentally ill.”

300 APPENDIX D

The American Hospital Association 1985 annual survey shows 10,595
full- and part-time occupational therapists employed in US. registered
hospitals. The American Occupational Therapy Association reports that
about 28 percent of its members worked in general and pediatric hospitals
in 1986. BLS estimates that 32.5 percent of total occupational therapy
employment is in hospitals.

The total active membership of registered occupational therapists in the
American Occupational Therapy Association at the end of 1987 was about
27,300. Until mid-1987, registered occupational therapists automatically
became members of the association, and the tally of active members rep-
resented about 99 percent of the professional work force. Membership in
the association is now voluntary.

Physical Therapists

Total 1986 employment of physical therapists was estimated by BLS to
be about 61,168 positions, including 5,000 self-employed persons. The CBS
deﬁnes physical therapists as persons who “apply techniques and treatments
that help relieve pain, increase the patient’s strength, and decrease or
prevent deformity and crippling.”

The American Physical Therapy Association estimated the number of
licensed physical therapists to be 65,890 as ofJune 1986. All states require
practicing professional physical therapists to be licensed.

Radiologic Technologists and Technicians

According to BLS estimates, there were 115,429 jobs for radiologic tech-
nologists and technicians in 1986. The CBS deﬁnes radiologic technologists
as persons who “take x-rays, CAT scans, or administer non—radioactive
materials into [a] patient’s blood stream for diagnostic and therapeutic
purposes.” Hospitals were asked to include in the category of radiologic
technologist all workers whose primary duties were to demonstrate portions
of the human body on x-ray ﬁlm or fluoroscopic screens. Radiologic tech-
nicians were deﬁned as persons who “maintain and safely use equipment
and supplies necessary to demonstrate portions of the human body on x-
ray ﬁlm or a ﬂuoroscopic screen for diagnostic purposes.” Included in the
BLS “radiologic technologists and technicians” category are radiation ther-
apists and sonographers. Nuclear medicine technicians are not included.

The Bureau of Health Professions estimates that there were 143,000
radiologic health service workers of all types in 1986, including nuclear
medicine technologists.

Nuclear Medicine Technologists

Nuclear medicine technologists “prepare, administer, and measure ra-
dioactive isotopes in therapeutic, diagnostic, and tracer studies utilizing a

APPENDIX D 301

variety of radioisotope equipment.” They “prepare stock solutions of ra—
dioactive materials and calculate doses to be administered by radiologists.”
They “subject patients to radiation [and] execute blood volume, red cell
survival and fat absorption studies following standard laboratory tech—
niques.”

BLS estimates that there were 9,677 nuclear medicine technologist jobs
in 1986, of which 89 percent were in hospitals. Over 88 percent of the
respondents to a 1987 survey conducted by the Nuclear Medicine Tech-
nology Certiﬁcation Board indicated that they worked in hospitals.

The 1985 American Hospital Association survey of US. hospitals indi—
cated that there were 7,972 full— and part-time nuclear medicine technol—
ogists employed in US registered hospitals in that year. If approximately
89 percent of all nuclear medicine technologists work in hospitals, the
American Hospital Association data suggest that the total number of nu-
clear medicine technologists employed in 1985 was about 9,000, which is
in close agreement with the BLS estimate. The Nuclear Medicine Tech-
nology Certiﬁcation Board reported 10,298 certiﬁed technologists in Au-
gust 1987.

Respiratory Therapists

BLS estimated that there were 56,333 jobs for respiratory therapists in
1986—there were no self-employed respiratory therapists. The OES de-
ﬁnes respiratory therapists as persons who “set up and operate various
types of equipment, such as iron lungs, oxygen tents, resuscitators, and
incubators, to administer oxygen and other gases to patients.”

The 1985 American Hospital Association survey indicated that there
were 32,623 respiratory therapists employed in US. registered hospitals
in that year. The American Association for Respiratory Care states that
the majority of respiratory care practitioners work in hospitals. BLS esti-

mates that 88 percent of such jobs are to be found in hospitals.

Speech Pathologists and Audiologists

BLS estimates that jobs for speech pathologists and audiologists num-
bered 45,129 positions in 1986, including 3,000 self-employed practitioners.
The OES deﬁnes speech pathologists and audiologists as health care prac-
titioners who “examine and provide remedial services for persons with
speech and hearing disorders and perform research related to speech and
language problems.”

The 1985 American Hospital Association survey identiﬁed 5,354 speech
pathologists and audiologists who were employed in US. registered hos-
pitals in that year. If, as BLS states, hospitals provide only about 10 percent
of total employment for speech pathologists and audiologists, the total

302 APPENDIX D

number of speech pathologists and audiologists employed in 1985 would
have been about 53,540—substantially higher than the BLS estimate.

There are 56,287 speech pathologists and audiologists who are certiﬁed
by the American Speech—Language—Hearing Association. N inety-two per—
cent of certiﬁed practitioners are members of the association. Although
basic occupational preparation is at the master’s level, persons holding only
a bachelor’s degree in speech pathology and audiology are employed in
some settings and may be considered a part of the labor supply. There is
no estimate of the number of bachelor’s—level practitioners.

APPENDIX

 

Projections of Demand and
Supply in Occupations

This appendix describes the purposes to which projections of worker
demand and supply are put and the characteristics these projections must
have if they are to serve these purposes. The various methods that have
been used for making projections are summarized, and the limitations of
each are discussed. The accuracy and limitations of the methods used by
BLS are also considered. A ﬁnal section points to needed research and
suggests how the projections can best be understood and used.

PURPOSES OF PROJECTIONS

Economic history amply demonstrates the rise and fall of industries and
of occupations. Fluctuations in supply are most likely in those occupations
that require long training periods; this pattern occurs because the supply
of workers in a particular field that develops in response to market signals
may take years to get through the educational pipeline. Workers investing
time and money in education, employers concerned about the availability
of skilled workers, and a public interested in stability of wages and prices
and in getting services when they need them all have an interest in our
ability to anticipate changes in employment at least a few years in the future.

Projections may be made for a variety of purposes, among which are
the following:

0 evaluating the adequacy of training or education programs in light of
the potential need for workers;

303

304 APPENDIX E

O estimating the feasibility of major proposed programs for government
expenditure (such as defense, public works, or facilities) in terms of the
availability of skilled workers to accomplish or staff them; and

0 providing information on future employment opportunities for the
guidance of individuals choosing courses of education or training.

Examples of the first of these purposes include the insistence of Congress
that federally supported programs of vocational education and training of
the unemployed or the disadvantaged be planned with future employment
opportunities in mind. Similarly, the congressional consideration of such
programs as highway construction, community mental health facilities, and
the Strategic Defense Initiative (“Star Wars”) programs—to name a few—
included an inquiry into the availability of the highly skilled personnel that
are required for these projects. BLS launched its occupational outlook
research program in 1940 in response to the concern of guidance profes—
sionals that young people have adequate information with which to choose
among careers. The same motivation lies behind the efforts of state gov-
ernments to provide local projections of employment growth by occupation.

The rationale and assumptions underlying the projections may differ
depending on the purposes these projections must serve. Both vocational
guidance and evaluations of the adequacy of training programs to meet
future needs for skilled workers call for a realistic estimate of future eco-
nomic demand in the occupation. Estimating the feasibility of proposed
human resources programs, on the other hand, calls for the translation of
program goals—whether or not they are realistic—into personnel, and
adding to these requirements a realistic estimate of the demand for the
same types of workers in the rest of the economy.

On the supply side, vocational guidance purposes require projections of
the most probable worker supply in comparison with the economic demand.
These types of projections give the best picture of future employment
opportunities and the competitive situation in each field. For evaluating
the feasibility of a proposed program a forecast of the most probable supply
is also desirable; such a forecast would show whether the program can be
accomplished without special measures to attract more workers to the ﬁeld.
For appraisals of the adequacy of present training programs, however, a
major element of the estimate of future supply—the number of trainees—
is the quantity for which the exercise is undertaken, the unknown in the
equation, and there is no need to estimate it independently. One way to
look at the supply is to treat the losses to the occupation resulting from
death, retirements, and net mobility to other occupations as components
of “replacement needs.” These replacement needs should be added to the
estimated growth of the occupation to get the total demand that has to be
satisﬁed by the flow of trainees.

APPENDIX E 305

In all of the above, we have discussed demand and supply as though
they were independent of each other; in fact, they are interdependent. An
increase in demand, by raising wage rates, elicits an increase in supply, and
supply also affects demand through its effects on wages and costs. Only
when there are constraints on demand, such as those imposed by the
technology of an industry (a steel mill cannot employ pastry cooks to roll
steel), or constraints on supply, such as limited educational facilities or
licensure, is the adjustment of worker demand and supply impeded.

Yet in those occupations that require long periods of education or train-
ing, it may take several years for the signal of an increase in demand to
fill the educational pipeline and produce an increase in graduates; it is for
these occupations that projections are particularly useful in facilitating the
adjustment of demand and supply. In the absence of projections, young
people have only the current market situation to guide them. If they react
strongly to a current shortage of graduates and high salary offers, they
may ﬁnd that when they graduate, 4 years later, the ﬁeld has become
overcrowded and salaries are dropping, conditions that may cause the
current year’s entrants to avoid the ﬁeld and precipitate a shortage 4 years
later. (The operation of “cobweb” patterns in the labor markets for highly
trained workers is demonstrated in a number of papers by Richard Free—
man.)

Projection Methods

A variety of methods have been used to project demand and supply.
The simplest has been to ask employers how many workers they expect to
employ in the future. This method appeals to many people as a straight-
forward way to tap the expert knowledge of the people who will make the
decisions. Yet it has produced such poor results that, after years of use, it
was abandoned early in the 19705. Researchers found that few employers
could make the necessary projections of their sales and of technological
changes in their industries to develop good estimates of their future oc-
cupational requirements. (Indeed, most employers do not reply to the
surveys or give casual, off-the—cuff answers.) There is some tendency for
each firm to assume it will gain a larger market share; and an offsetting
tendency for companies to report that their personnel requirements 5 years
in the future will be the same as they are now. Finally, this method makes
no allowance for employment in new firms, which, according to some
research, are and will be a major provider of additional employment.

A second method that has been used to project demand and supply is
to extrapolate past employment trends in the occupation. This method is
based on the assumption that, whatever factors have operated in the past
will continue to operate. Unfortunately, history is full of instances in which

306 APPENDIX E

the employment situation changed radically—as any buggy whip manu-
facturer will attest. Another deﬁciency of this method is its tendency to
treat the occupation as if it were in a vacuum and unrelated to other events
in the economy and in society. This limitation is illustrated by the attempt
in the early 19505 to extrapolate the growth of the engineering profession
by assuming that the exponential growth it had shown would continue.
With such growth, engineers would have exceeded the total labor force in
a short time, leaving no draftsmen to prepare drawings, no bookkeepers
to pay salaries, and no trash collectors to haul away their refuse.

A more sophisticated approach of late has been to associate the growth
of an occupation with causative variables that can themselves be projected
independently. For example, projections of the population by age have
been used to project the demand for teachers: the pupils in elementary
grades 6 years hence have already been born, as have those who will be
high school students 14 years hence. Changes in pupil—teacher ratios or
other strategic variables can be used to modify the results of these projec-
tions. Similar methods have been used to project the demand for physicians
(Graduate Medical Education National Advisory Committee) and nurses
(Western Interstate Committee on Higher Education). In some cases,
regression analysis has been used to measure the relative effects of the
variables on the result: the projection of employment.

This method may be used to yield estimates of the need for workers in
the occupation rather than estimates of the economic demand. If the rel—
evant ratios (e.g., the pupil—teacher ratio in the projection of employment
for teachers) are set at an ideal level that is nevertheless in line with what
experts in the ﬁeld consider optimum, the resultant projections can be
viewed as projections of need. To the extent that they are based on current
ratios, which in turn reﬂect the current market situation, or are adjusted
for the future to reﬂect expected changes in the market situation, the
resultant estimate will be closer to an estimate of demand. Each approach
serves a different purpose.

The advantages of this approach over the simple extrapolation of past
trends are obvious. This method attempts to take into account some of the
strategic factors affecting employment. This is not an easy task, however;
demand in an occupation may be affected by technological changes; market
Changes; the way consumers spend their money and" the amount of income
they have to spend; government expenditures on education, health, high-
ways, and military material; and the capital expenditures of industry. Even
more important than these factors are the context of the growth of related
occupations and industries and the entire interwoven structure of the econ-
omy and of society. When we consider the combination of factors that
affect employment in health occupations—for example, the importance of
population trends, social trends, income and expenditure patterns, the

APPENDIX E 307

science and technology of medical practice, the ﬁnancing of medical care,
training and licensure, and the growth and attractiveness of alternative
occupations—it becomes apparent that a comprehensive approach is called
for.

BLS, which began its research in this area in 1940 and issued its first
occupational projection 5 years later, at first tried the approach of studying
individual occupations but concluded that a comprehensive analysis was
needed. With support from the Veterans Administration (which wanted
information to help in the vocational choices of the millions who studied
under the World War 1 GI. Bill), BLS published outlook information on
hundreds of occupations beginning with the first Occupational Outlook H and-
book in 1949. The handbook has been a biennial publication since the mid-
19505.

The broad occupational coverage, frequent publication, and wide use of
the projections (150,000 copies of each edition of the handbook are bought
by high schools, colleges, libraries, and community agencies) have had
important implications for the research program. Spreading research costs
over so many occupations has allowed a more comprehensive approach
than could be supported if interest were focused only on a few occupations.
The continuing research effort has led to accumulating experience, deep-
ening knowledge of each occupation, and ongoing contacts with industry,
professional organizations, unions, and research institutes that are familiar
with each ﬁeld. It has also permitted regular appraisals of the accuracy of
the projections and analyses of the possible reasons for errors. As a result
of this experience, new research programs and data collection systems have
been instituted, an example of which is the occupational employment sta-
tistics program begun in the early 19705. Research is also being conducted
on tables of working life and on how people move from one occupation
to another, one purpose of which is to develop insight into some of the
elements of supply. Over nearly five decades of experience, occupational
research methods have changed and improved. The wide publication of
the results of such research has ensured that industry and professional
groups in each occupation have cooperated with the bureau in giving
information and carefully reviewing drafts. The use of research results in
schools and in vocational guidance undoubtedly inﬂuences the perceptions
of students about employment opportunities and the occupational choices
they make.

The basic approach followed by BLS is to estimate the employment in
each occupation that will be generated by economic demand. This estimate
is based on the demand for the goods or services the occupation provides,
which in turn is affected by the total spendable income available to con-
sumers and governments and by the changing patterns of what they spend
it on. These patterns are inﬂuenced by a wide variety of social and economic

308 APPENDIX E

factors, including changing tastes and styles, scientiﬁc discoveries and tech-
nological change affecting both what is produced and how it is produced,
the growth and changing composition of the population, taxation and
government expenditure policies (“guns or butter”), and what other coun-
tries are buying from and selling to us.

Producing such estimates is a formidable task, and predicting what will
happen in the future on so many different fronts is hazardous. Natural
disasters, social cataclysms, and business cycles are hard to predict. Yet
some of the changing factors move relatively slowly: there are lags between
scientific discoveries and the commercial exploitation of new technology,
between the initiation of a new style and its widespread adoption, between
the ﬁrst japanese automobile sold in the United States and japan’s sub-
sequent market success. These lags mean that useful projections can be
produced, provided certain conditions are met: (1) projections are confined
to a relatively short time horizon (about 10 years is enough to guide ed-
ucational policy and the career choices of individuals); (2) sets of alternative
projections are made to show the effect, for example, of alternative as-
sumptions as to the state of the economy or the business cycle; (3) events
are constantly monitored; (4) the projections are revised at frequent in—
tervals; and (5) continuous research is carried out on the accuracy of the
projections and on the adequacy of the methods.

BLS projections begin with the population projections made by Census
Bureau demographers. The census data give the number of consumers
and are a basis for BLS’s projections of the labor force, which are based
on the trends in labor force participation by each age, sex, and race group.
From the total human resources thus projected, BLS estimates the gross
national product (GNP) that will be generated by making assumptions about
the growth of output per worker, changing hours of work, and the level
of unemployment that must be taken into account. To provide for the
uncertainties of the business cycle and to suggest the range of error to
users of the projections, three sets of projections are usually made: a “high,”
“moderate,” and “low” forecast. The BLS assumptions about productivity,
hours, and unemployment are adjusted to yield an estimate of GNP growth
under these three conditions.

This somewhat simplified recital of an elaborate process may give the
impression of a mechanical juggernaut that rides roughshod over the entire
economy of 110 million people with all its complexity, nuances, and infinite
variety, mashing up the professions in which we are interested with masses
of coal miners, factory workers, and fast-food slingers. What has not been
said is that, at each step of the BLS process, special knowledge is introduced
whenever it is available, and the factors that enter into the calculations are
adjusted on the basis of information on developing and newly emerging
trends in the industry. In the most recent projections, for example, forecasts
for the mining industries took into account the latest petroleum import

APPENDIX E 309

analyses for the target year from the Department of Energy. Projections
for the machinery and computer manufacturing industries incorporated
analyses of the market situation and foreign competition. Projections for
health services considered such developments as cost containment policies,
the shift of many surgical procedures to physicians’ ofﬁces and outpatient
facilities, the growth of new group practices and nursing and personal care
facilities, and the aging of the population. The bureau’s extensive research
program on productivity and technological development yields insights
about the growth of overall productivity and of productivity in each in-
dustry, and the technological developments that affect the numbers and
kinds of occupations that are employed. The advantage of the compre-
hensive interactive approach is that special information or analyses on any
aspect of our complex economy can be inserted and implications drawn—
not only for a particular occupation or industry but for all of the others
as well.

In contrast, there is no unifying and systematic method for projections
on the supply side. The supply of workers in an occupation is affected by
two factors: (1) the inflow of trainees and of persons who acquire the
necessary skills by experience or work in related occupations or by the
study of related subjects and (2) the outﬂow of persons retiring, dropping
out of the labor force temporarily, dying, or transferring to other occu-
pations. Supply, of course, is also affected by the relative wages in this and
other occupations available to workers.

Projections of the number of college graduates in each ﬁeld have been
published by the Department of Education; they were based on the pro-
jected population of the appropriate age and on mathematical extrapola-
tion of trends in the proportion of the population completing college. The
total degrees awarded were distributed by ﬁeld (college majors) using math-
ematical extrapolation of past trends. Because there was no attempt to take
into account the effects of social and market factors on the decisions of
young people (except insofar as these factors were embodied in projected
past trends), these projections cannot be considered realistic. They do,
however, serve a useful purpose: they can be used to illustrate what would
happen to the outﬂow of graduates, an important component of the supply
of workers, if nothing happened to change the choices people make about
future careers. If such estimates are compared to independent estimates
of future demand or the requirements for attaining some national goal
such as a proposed community mental health program, a disparity between
the projected demand and the projected supply could point to policy mea-
sures that might be required to attain the goals (e.g., scholarships or other
inducements to undertake training for the occupations).

To determine the outﬂows and inflows that affect occupational supply,
BLS has pursued a number of avenues of research. For example, the
bureau has developed tables of working life (similar to life tables), showing

310 APPENDIX E

the annual attrition to a population at each age, to estimate losses resulting
from deaths and retirements. These age-specific rates were then applied
to the age composition of each occupation to estimate annual losses. The
tables take no account of differences in work life patterns among occu-
pations, however, nor of losses resulting from transfers to other occupa-
tions. More recently, studies have been made of transfers into and out of
occupations (Eck, 1984), and more complete attrition rates for each oc-
cupation have been estimated, including shifts into unemployment and
withdrawal from the labor force (either retirement or temporary with-
drawal).

BLS does not make projections of worker supply in occupations. It does
publish estimates of annual attrition or replacement rates. This information
is offered, together with the projected rate of growth in each occupation
and information on the unemployment rate, as clues to the employment
opportunities in the occupation. The inclusion of information on replace-
ment rates makes clear the point that projected growth alone does not tell
the whole story about employment opportunities.

Projections of employment demand for more than 300 occupations are
published in technical articles and bulletins. (The most recent projections
of general economic growth, industrial growth, and occupations were pub-
lished in the September 1987 issue of Monthly Labor Review). Brief articles
on each of about 200 occupations involving relatively long periods of train-
ing are published in the Occupational Outlook Handbook; proﬁles of the basic
numbers—employment, projected employment growth, unemployment rates,
replacement rates, and number of people completing training in a recent
year—~for about the same number of occupations are published in a series
of bulletins called Occupational Projections and Training Data, of which the
most recent (BLS Bulletin 2206) was issued in 1984.

State and Local Projections

In most states, employment projections for the state and major geo-
graphic areas within the state are made by state agencies, most commonly
employment security agencies, but sometimes universities or other eco-
nomic analysis organizations. Until a few years ago, there was a cooperative
federakstate relationship in this work, with BLS providing technical con—
sulting and sometimes tabulation work, but this cooperation has been dis-
continued as a result of budget cuts. The states are continuing their work,
however. The National Occupational Information Coordinating Commit-
tee, which is composed of representatives of the Departments of Labor
and Education, and its afﬁliated state occupational information coordinat-
ing committees give leadership to these efforts.

The states use varying methods, but they all have a few elements in
common. The national projections of the growth of industries are generally

APPENDIX E 3 l 1

taken as a framework, and past changes in each state’s share of national
employment in the industry, together with projections of the state’s pop-
ulation and any available input from the economic development agency of
the state, are used to project the industry’s growth locally. Industry occu-
pational composition data from the Occupational Employment Survey (which
is conducted by the state agencies in cooperation with BLS) are used to
project employment by occupation. Replacement rates provided by BLS
are also published.

Evaluation of BLS Projections and Methods

Any evaluation of BLS’s projection methods should begin with a look at
the scorecard—~that is, at how accurate the projections have been. The
bureau has published a number of evaluations of the accuracy of its pro-
jections, comparing them to actual employment in each industry and oc-
cupation when the target year’s statistics become available. The two most
recent evaluations will be analyzed here: those for the 1960—1975 projec-
tions (Carey, 1980) and the 1970—1980 projections (Carey and Kasunic,
1982). (No more recent evaluations have been published, in part because
changes in the classiﬁcation system for occupations have made it difficult
to compare earlier projections with employment data gathered since 1983.)

Comparing a projection that purports to reflect demand, without regard
to supply, with the actual employment in the target year is not entirely
logical. It is justiﬁed only if one can assume that the supply will adjust itself
to match the demand, which does not always happen.

There are a number of ways to consider the accuracy of projections. One
is to compare the number of workers employed in the target year with the
number projected. The purpose of the projections, however, is to anticipate
change, to distinguish occupations that are growing rapidly or slowly, and,
especially, to perform the more difﬁcult task of identifying occupations
that shrink while the economy as a whole is growing. Our evaluation will
therefore concentrate on how well the rate and direction of change in em-
ployment was projected.

To begin with, we must look at the degree of variabilty in growth rates
among occupations. If growth rates vary in a narrow range around the
average, we would expect projections to be fairly accurate; if growth rates
are widely dispersed, the projections may be judged by more lenient stan-
dards. Table E-1 arrays the actual changes in employment in occupations
included in the two BLS evaluation studies referred to above according to
broad groupings of their rates and directions of change as compared to
the average change for all occupations.

This little table could well have been made the preface of this paper: it
powerfully demonstrates the variability of occupational change, the risk
undertaken by anyone who invests in long and expensive training for an

3 12 APPENDIX E

occupation, and the difﬁculties of the forecaster. In a 10- or 15-year period
when the average occupation grew by about 30 percent, between one-ﬁfth
and one-third of the occupations under study actually experienced declines
in employment. The number of occupations that grew at a rate triple the
average was about the same as the number that grew at a rate less than
the average. There was virtually no clustering around the average. Ob—
viously, occupations are highly volatile in their rates of employment and
subject to diverse economic forces.

An evaluation (Goldstein, 1983) of how well the BLS projections for
these occupations succeeded in predicting the actual changes shown above
concluded that, ﬁrst, users of the projections had some warning of the
declines: 5 of the 16 occupations that declined from 1960 to 1975 had been
predicted to decline, and small increases of less than the average had been
predicted for the other 11. In the 1970—1980 period, 6 of the 20 occu-
pations that declined had been projected to decline, and small increases of
less than the average had been projected for 7 more.

Second, did the projections identify the occupations that were growing
rapidly and that needed special attention in planning training programs?
In the ﬁrst period, 21 occupations grew at more than twice the average
rate; 15 of them had been projected to grow that fast. In the second period,
14 occupations grew at more than twice the average rate, but in only 2 of
them had such growth been projected.

Taking all of the projections together, how close did they come to the
actual employment changes that occurred? Going back to the class intervals
shown in Table E-l, we might say that if the predicted change was in the

TABLE E-l Growth Rates in Employment in Occupations with
Increases and Decreases in Employment, 1960—1975 and 1970—1985

 

 

Item 1960—1975 1970—1985
Average (weighted) change (in percentage) for
all occupations 32.6 28.9
Total number of occupations compared 76 64
Occupations with declines in employment 16 20
Occupations with increases in employment 60 44
Below average (more than 10 percent below
the average) 11 10
About average (within 10 percent above or
below the average) 17 9

Somewhat above the average (between 10
percent above the average and twice the

average) 1 1 1 1
Twice to triple the average 11 5
More than triple the average 10 9

 

SOURCE: Carey (1980); Carey and Kasunic (1982).

APPENDIX E 313

TABLE E-2 Projected and Actual Employment Changes (percentage)
for Six Health Occupations, 1960—1975

 

 

Occupation Projected Actual
Nurses, professional 73.5 68.5
Dietitians and nutritionists 35.1 44.6
Optometrists 17.6 10.0
Attendants, hospital and other institutions 140.7 122.4
Dentists 43.8 23.1
Physicians, medical and osteopathic 66.7 40.2

 

SOURCE: Carey (1980); Carey and Kasunic (1982).

same interval as the actual change, it was on target. For the ﬁrst period,
40 percent of the predictions were on target; for the second, 33 percent
were on target. If we consider as reasonably close those predictions that
were in the class intervals adjacent to the actual change, we ﬁnd that 40
percent of the predictions in the ﬁrst period and 27 percent of those in
the second period were reasonably close. By these standards, which are
perhaps somewhat lenient but whose leniency is justiﬁed by the variability
of economic employment changes, we would consider 80 percent of the
projections in the ﬁrst period and 60 percent in the second to be either
on target or reasonably close.

Another question that must be answered is: Were the errors biased so
that projections were consistently too high or too low? Of all the projections
in the ﬁrst period that were not on target, one-third were too low; in the
second period, roughly half were too low. Thus, there is some evidence of
a pessimistic bias in the second period.

Our concern in this report is somewhat more narrow, however. We must
thus consider how well the method predicts the growth of the the allied
health occupations. It is a reasonable hypothesis that the economic, tech—
nological, social, and institutional factors that are peculiar to the health
industry and its occupations may make the general projection method used
by BLS inappropriate for use in these ﬁelds.

The evaluation studies we have cited do not include many of the allied
health professions, largely because they included only occupations for which
the statistics were comparable over the 10- or 15-year spans between the
original projections and the target years. The comparison data needed for
the allied health professions, with their dynamic changes over recent de-
cades, are not available. Yet we can still test the hypothesis of peculiarity
with evaluations of the accuracy of the projections for other health occu—
pations (Tables 13-2 and E-3).

It appears that the projections captured the general magnitude of the
employment changes in these ﬁelds rather better than they did for all of
the occupations evaluated earlier in this section, although one could wish

314 APPENDIX E

TABLE E-3 Projected and Actual Employment Changes (percentage)
for Five Health Occupations, 1970~1980

 

 

Occupation Projected Actual
Optometrists 20.0 19.4
Osteopaths 43.7 39.3
Physicians and surgeons 48.5 43.3
Registered nurses 42.7 59.9
Dentists 32,0 22.3

 

SOURCE: Carey (1980); Carey and Kasunic (1982).

for more accurate projections for dentists and physicians in the ﬁrst period
and for nurses in the second. From these data, the hypothesis of peculiarity
of the health fields is not supported. Let us turn, however, to some of the
aspects of the projection method that raise questions or present problems.

Demand or Requirements?

In traditional economic analysis, demand and supply are equated at a
price or wage. Yet there is no explicit evidence of this process in the BLS
projection methods. Instead, the employment estimates for future years
may be seen as requirements generated by the levels of production or
services that the projected economic changes will engender. Indeed, chang-
ing relative prices throughout the system could change the projected eco-
nomic relationship—for example, in tracing the demand for raw materials
generated by the production of ﬁnished goods. However, the adjustments
made at various steps in the projection process to introduce technological
change and changes in markets and foreign trade have the effect of in-
serting price and market changes into the system.

At the end of the process, it is true that there is no systematic attempt
to modify the employment estimates for each occupation by a consideration
of supply. Indeed, as the forecasters lack projections of supply, this cannot
be done. The projections of occupational employment will be consistent
with actual employment in the target year only if the supply of trained
workers (perhaps forewarned by publication of the estimates or, in the
19603, responding to policy measures that were designed to raise supply
to meet increased demand resulting from new entitlement programs) ad-
justs to the employer’s requirements. Although the projections are not true
estimates of demand in the sense of traditional economic concepts, they
do come close to the goal of a realistic estimate of the number of jobs that
will be offered, as distinct, for example, from an estimate of ideal needs.

Occupational Composition of Industries

Evaluations of the accuracy of the projections made by BLS staff have
concluded that the subject industries’ total employment was more accurately

APPENDIX E 315

projected than was employment by occupation. From the foregoing dis-
cussion, we might suspect that the lower accuracy of occupational projec-
tions may have resulted from the fact that demand had not yet been
confronted with supply. If it had, a different level of employment would
have emerged.

Less accuracy could also have been the result of the quality of the oc—
cupational data; until recently the only reasonably complete source of data
on the occupational composition of each industry was the decennial pop-
ulation census. In household surveys such as censuses, people report their
occupation by whatever name they have to describe it, telling the census
enumerator brieﬂy what activities they perform. These reports are classified
by census clerks into the approximately 400 occupations the census tabu-
lates. There is potential error ﬁrst in the respondent’s report: some people
overstate their occupational status, as is evident from independent data.
Second, the census clerks do not always have enough information to classify
the occupations correctly; terminology varies across the country. (The same
comments apply to another source of occupational employment data, the
Current Population Survey, which is conducted by the Census Bureau. The
occupational estimates of this survey are based on a smaller sample than
those in the population census and thus have larger sampling errors and
somewhat less occupational detail; however, they are available annually.)

To improve the accuracy of occupational composition data, BLS initiated
an Occupational Employment Statistics (OES) survey, early in the 19705 in
cooperation with state agencies. Employment by occupation is collected
from employers by means of a separate questionnaire for each industry
that lists the occupations found in that industry. The questionnaire contains
brief deﬁnitions of the occupations that have been worked out in consul-
tation with employers to ensure understanding and accurate reporting.
The sample plants in the survey are chosen to represent all size classes in
the industry and to yield accurate estimates.

The survey is limited to wage and salary workers in each industry; BLS
adds the self-employed in each occupation using data from the Current
Population Survey.

Because it is based on reports from employers, the DES counts each
worker more than once if he or she has more than one job at a time. This
practice introduces a small inaccuracy in the occupation employment es-
timates; in the series of surveys of dual job-holding that was made from
1958 to 1980, the number of persons with more than one job averaged
about 5 percent of the total employed—the exact figures were 6 percent
for men and 3 percent for women.

The BLS estimates count workers whether they work full-time or part-
time and do not distinguish between these two categories. Thus, in any
occupation, there could be many part-time workers in the ﬁgures. In 1986,
18.7 percent of all persons at work were working part-time—5.3 percent

3 16 APPENDIX E

for economic reasons (no full—time work was available or they had been
temporarily assigned to part-time work) and 13.4 percent because they
preferred part-time work. There was more part-time work among women—
27.5 percent of women worked part-time, 6.5 percent for economic reasons
and 21 percent voluntarily. The incidence of part-time work varies among
occupations, in the occupation group “technicians and related support
personnel,” in which many allied health professions are included, 12.9
percent of workers were part-time (2.2 percent for economic reasons):
among women technicians, 20 percent were on part—time (3.4 percent for
economic reasons). (All data in .this paragraph are from the Current Pop-
ulation Survey.) There are therefore fewer FTE (full-time equivalent) jobs
than the number of people employed in an occupation implies.

The deﬁnitions of each occupation worked out for the OES were, as
noted above, designed in cooperation with employers to facilitate reporting.
The deﬁnitions must be understood within the culture of each industry
and must be consistent across industries so that the employment estimates
for each occupation are additive. This qualiﬁcation, however, may not
always provide the nuances in deﬁnition that professional societies—con-
cerned about qualiﬁcations, licensure, and similar matters—would like to
have. Appendix C lists allied health occupations and related occupation
deﬁnitions.

We have suggested two reasons for the lower degree of accuracy of the
occupational employment projections compared with those for industry
employment: (1) the demand projections are not tested against occupational
supply and (2) the basic data on the occupational composition of industries
used in past projections were inaccurate. We should consider a third reason:
the way in which occupational composition is changing is not well under-
stood, and the adjustments inserted into the system to allow for the effects
of technological and other changes thus are not adequate.

The theory underlying the use of occupational composition data in fore-
casts is that the technology of each industry and the way it does its business
calls for a unique mix of occupations. In a gross sense, this is certainly true:
pastry cooks are not employed in steel-rolling mills. But there could be
differences among plants in the same industry that result from differences
in processes, in equipment, in the way the work is organized, and in the
local supply of trained workers and the extent to which less-trained workers
are substituted for them. For those familiar with hospitals and other health
service institutions, there is no need to belabor the point that occupational
composition may differ from one to another for many reasons.

When the acting commissioner of the Bureau of Labor Statistics ﬁrst
testiﬁed before Congress on the request for funds to conduct occupational
outlook research, he stated that the research would consider the occupa-
tional composition of the most technologically advanced plants in each

APPENDIX E 317

industry for clues as to the way composition would be changing. Now,
nearly half a century later, this kind of analysis is made possible for the
ﬁrst time by the DES. Not only are the occupational statistics better but
the collection of reports from individual plants offers a potential that has
never before been available except from a few industry wage surveys: The
chance to analyze why the occupational composition differs among plants
in the same industry and how it is affected by the size of the plant and by
new technology—analyses that may lead to better projections of occupa-
tional employment.

Stafﬁng of the Projections Research

The number of BLS occupational outlook research staff has been re-
duced over the past few years as a result of budget cuts, and the burden
on individual staff members has therefore increased. With some 200 oc—
cupations to cover with articles in the Occupational Outlook Handbook, staff
are spread thin. Nevertheless, when the National Academy of Sciences staff
visited them to discuss their projections, it was found that no fewer than
four economists were working on health occupations. They were in touch
with developments in their ﬁelds and in the health care industry generally
and were familiar with the issues and findings of recent studies.

Use of the Projections and Further Research Needs

It should be apparent that forecasting for years in advance is always
hazardous and that this truism applies particularly to employment by oc-
cupation. While there is always hope that the data and methods will improve
in the future, the best we can realistically expect is that the degree of error
will be somewhat reduced. The user of projections must bear this in mind
and take them as only rough indications of the direction and general
magnitude of changes.

Of the projection methods we have reviewed, that of the Bureau of
Labor Statistics appears to be the best in its ability to take into account
multiple factors. BLS staff have been doing such projections continuously
for a long time; they have accumulated experience, knowledge, and contacts
in each ﬁeld; and they check their errors and are innovative in improving
data collection and analysis methods.

For any projections of employment in the allied health professions the
Institute of Medicine committee would be well advised to build on the work
BLS has done—not necessarily to accept the projections without question
but to take advantage of the analysis of the framework of the US. economy
within which the health industry operates, and to examine the assumptions
and judgments made by BLS staff in the health ﬁelds, modifying them if
necessary. Our discussions with BLS staff made it clear that they are ear—

3 18 APPENDIX E

nestly searching for understanding and would welcome any insights that
would improve their projections.

Before we can have any assurance that occupational supply can be un-
derstood or projected, more research needs to be done on occupational
mobility and the factors that determine how people shift employment among
occupations. The same may be said about the factors affecting occupational
choice.

On the demand side, the weakest link has been in converting projections
of employment by industry, which have a fair degree of accuracy, into
projections by occupation. Now, however, analysis of the factors that affect
the occupational composition patterns of industries can be performed be-
cause for the ﬁrst time we have occupational data for individual plants.

BLS practice in publishing its projections has been to issue only 10-year
or longer projections (without the intermediate years). Yet intermediate—
year projections are likely to be more accurate because they are closer to
what we now know; in addition, they are useful for many purposes. They
also lend themselves to more frequent evaluations of accuracy, a practice
that, if adopted, would enable BLS to correct its more distant projections.

REFERENCES

Carey, M. L. 1980. Evaluating the 1975 projections of occupational employment. Monthly
Labor Review lOSGune):10—20.

Carey, M. L., and K. Kasunic. 1982. Evaluating the 1980 projections of occupational
employment. Monthly Labor Review 1050uly):22—30.

Eck, A. 1984. New occupational separation data improve estimates of job replacement
needs. Monthly Labor Review 107(March):3—10.

Goldstein, H. 1983. The accuracy and utilization of occupational forecasting. In Respon-
siveness of Training Institutions to Changing Labor Market Demands, R. E. Taylor,
H. Rosen, and F. C. Pratzner, eds. Columbus, Ohio: The National Center for Research
in Vocational Education.

APPENDIX

 

Minnesota Sunrise Provisions

MINNESOTA STATUTE 214 (ENACTED 1976),
SECTION 214.001

Subdivision 1 . The legislature finds that the interests of the people of the
state are served by the regulation of certain occupations. The legislature
further ﬁnds: (I) that it is desirable for boards composed primarily of
members of the occupations so regulated to be charged with formulating
the policies and standards governing the occupation; (2) that economical
and efﬁcient administration of the regulation activities can be achieved
through the provision of administrative services by departments of state
government; and (3) that procedural fairness in the disciplining of persons
regulated by the boards requires a separation of the investigative and pro-
secutorial functions from the board’s judicial responsibility.

Subdivision 2. Criteria for regulation. The legislature declares that no reg—
ulation shall be imposed upon any occupation unless required for the safety
and well being of the citizens of the state. In evaluating whether an oc—
cupation shall be regulated, the following factors shall be considered:

(a) Whether the unregulated practice of an occupation may harm or
endanger the health, safety and welfare of citizens of the state and whether
the potential for harm is recognizable and not remote;

(b) Whether the practice of an occupation requires specialized skill or
training and whether the public needs and will benefit by assurances of
initial and continuing occupational ability;

(c) Whether the citizens of this state are or may be effectively protected
by other means;

319

320 APPENDIX F

(d) Whether the overall cost effectiveness and economic impact would
be positive for citizens of the state.

Subdivision 3. If the legislature finds after evaluation of the factors iden-
tified in subdivision 2 that it is necessary to regulate an occupation not
heretofore credentialed or regulated, then regulation should be imple-
mented consistent with the policy of this section, in modes in the following
order:

(a) Creation or extension of common law or statutory causes of civil
action, and the creation or extension of criminal prohibitions;

(b) Imposition of inspection requirements and the ability to enforce
violations by injunctive relief in the courts;

(c) Implementation of a system of registration whereby practitioners
who will be the only persons permitted to use a designated title are listed
on an ofﬁcial roster after having met predetermined qualiﬁcations [note
that legislative action is not required here]; or

(d) Implementation of a system of licensing whereby a practitioner must
receive recognition by the state that he has met predetermined qualiﬁca-
tions, and persons not so licensed are prohibited from practicing.

MINNESOTA RULES 4695.0800: FACTORS FOR
DETERMINING THE NECESSITY OF REGULATION

Subpart 1. Consideration of factors. In the review of an applicant group
questionnaire, the subcommittee, council, and commissioner shall base their
recommendation or decision as to whether or not the applicant group shall
be regulated upon the factors contained in Minnesota Statutes, section
214.001, subdivision 2.

Subpart 2. Factor of unregulated practice. In applying the factor of whether
the unregulated practice of an occupation may harm or endanger the
health, safety, and welfare of citizens of the state and whether the potential
for harm is recognizable and not remote, at minimum the relevance of the
following shall be considered:

A. harm shall be construed to be a condition representative of physical,
emotional, mental, social, ﬁnancial, or intellectual impairment resulting
from the functions rendered or failed to be rendered by the applicant
group;

B. potential for harm may be recognizable when evidenced by at least
one or more of the following: expert testimony; client, consumer, or patient
testimony; research findings; legal precedents, financial awards, or judicial
rulings;

C. potential for harm may be recognizable when evidenced by at least
one or more of the following characteristics of the applicant group;

APPENDIX F 321

(1) inherently dangerous nature of the applicant group’s functions;
(2). dangerous nature of devices or substances used in performing
applicant group’s functions;

(3) exercise by practitioners of the applicant groups of an observable
degree of independent judgment when: identifying or evaluating a
consumer’s or client’s symptoms; formulating a plan for consumer
or client care, service delivery or treatment; and/or providing con-
sumer or client care, delivering service, or implementing a plan of
treatment;

D. potential for harm may be remote when evidenced by at least one
or more of the following: infrequent or rare instances 0f impairment;
impairment which is minor in nature; or secondary or tertiary effects of
the applicant group’s function.

Subpart 3. Occupation requiring special skill factor. In applying the factor of
whether the practice of an occupation requires specialized skill or training
and whether the public needs and will beneﬁt by assurances of initial and
continuing occupational ability, the existence of the following items shall
be considered as indicating that specialized skill or training or their con-
tinuation is required:

A. that the functions performed by the practitioner are several and their
performance necessitates a thorough understanding of the complex rela-
tionship between those functions;

B. that the one or more functions performed by the practitioner requires
a detailed understanding of the specific components of the function and
the relationship between the functions and the symptoms, problem, or
condition that function is intended to address or ameliorate;

C. that the absence of specialized skill or training is likely to increase
the incidence and/or degree of harm as defined in subpart 2 t0 the con-
sumer as client; and

D. that there occur frequent or major changes in areas of skilled knowl-
edge and technique of which the practitioner must keep informed in order
to meet current standards.

Subpart 4. Factor of more effective means. In applying the factor of whether
the citizens of this state may be effectively protected by other means, at a
minimum the relevance of the following shall be considered:

A. Indicators of protection by other means shall include but not be
limited to:

(1) supervision by practitioners in a regulated occupation;

(2) existence of laws governing devices and substances used in the
occupation;

(3) existence of laws governing the standard of practice;

(4) existence of standards for professional performance;

322 APPENDIX F

(5) employment in licensed human service facilities which are re-
quired to employ competent staff;
(6) existence of federal licensing as credentialing mechanism;
(7) existence of civil service procedures which effectively screen po-
tential employees for competence;
(8) graduation of members of the applicant group from an accred—
ited educational institution or training program;
(9) mandatory participation in on—the-job training programs which
are required by law or by professional organization of the occupation;
(10) existence of professional credentials and standards of perfor-
mance which effectively sanction malpractice; and
(11) existence of a national certiﬁcation process which effectively-
attests to the competency of recognized professionals.

B. Indicators of protection by other means shall be assessed and eval-

uated at least in view of the extent to which they:

(1) address all practitioners within an occupational group;
(2) appear sufﬁcient to protect the general public from harm caused
by the practice of the occupation in question; and
(3) appear to be permanent and ongoing mechanisms.

Subpam 5. Overall cost eﬂectivemss and economic impact. In determining whether
the overall cost effectiveness and economic impact would be positive for
citizens of the state, the following shall be considered:

A. Positive cost effectiveness and economic impact results where the
beneﬁts expected to accrue to the public from a decision to regulate an
occupation are greater than the costs resulting from that decision.

(1) Cost effectiveness means the relationship of the beneﬁts antici-
pated from a decision to regulate an occupation to the overall costs
to the public resulting from that decision.

(2) Economic impact means the direct and indirect effects on the
price and supply of services provided by the occupation under con-
sideration for regulation. Direct effects include impacts on the cost
and supply of practitioners who would be regulated. Indirect effects
include: the degree to which the existing practitioners will be pre-
cluded from practice because of regulation; the degree to which
persons aspiring to practice the occupation, who if not for regulation
could practice the occupation successfully, but will be prohibited be—
cause of inability to meet entry requirements; impact on ability of
minorities or protected classes to enter occupation; or impact on
innovations in the delivery of care or services as a result of regulation.
(3) Costs of a decision to regulate include the estimated costs to state
and local governments of administering the proposed regulatory pro-
gram; educational requirements and training costs including costs

APPENDIX F 323

associated with experiential requirements of the proposed mode of

regulation; and costs to the public such as reduced or increased access

by potential or existing providers to labor markets.
(4) Beneﬁts of a decision to regulate an occupation include access to
less expensive but similar providers; measurable improvements in
quality of care; reductions in costs of services; process for seeking
redress for injury from malpractice, or other unprofessional conduct;
and reduction in the potential for public harm from unregulated
practice.

B. Cost effectiveness and economic impact can be evaluated through

consideration of the following factors:
(1) degree to which regulation directly or indirectly impacts the costs
and prices of goods or services provided by applicant group;
(2) impact upon the current and future supply of practitioners of
the regulated occupation;
(3) degree to which existing practitioners will be precluded from
practice because of regulation;
(4) impact, if any, on innovations in delivery of care or services as a
result of regulation;
(5) costs of additional education and training required as a result of
the regulation of the occupation;
(6) manner in which and degree to which regulation will result in
improvement in the quality of care;
(7) degree to which services of the applicant group substitute for
currently regulated occupations and estimated comparative cost of
applicant group and currently regulated practitioners;
(8) degree to which services of the applicant group supplement cur-
rently regulated occupations;
(9) whether regulation confers or facilitates access to reimbursement
for government assistance programs such as Medicare and Medicaid;
estimated impact on programs and budgets; and
(10) impact on expenditures by government and private third party
payors, if any, resulting from regulation of the occupation.

APPENDIX

 

National Commission for
Health Certifying Agencies’
Criteria for Approval of
Certifying Agencies

A certifying agency responsible for attesting to the competency of health
care practitioners has a responsibility to the individuals desiring certiﬁca-
tion, to the employers of those individuals, to those agencies that reimburse
for the services, and t0 the public. The National Commission for Health
Certifying Agencies was formed to identify how those varying responsi-
bilities can be met and to determine if a certifying agency meets those
responsibilities. Membership of a certifying agency in the Commission in—
dicates that the certifying agency has been evaluated by the Commission
and deemed to meet all of the established criteria. In order to be “approved”
for membership in the commission, a certifying agency* shall meet the
following criteria:

1. Purpose of Certifying Agency
a. shall have as a primary purpose the evaluation of those individuals
who wish to enter, continue and/0r advance in the health profes-
sions, through the certification process, and the issuance of cre-
dentials to those individuals who meet the required level of
competence.

2. Structure
a. shall be non-governmental;
b. shall conduct certiﬁcation activities which are national in scope;

*Amended December 1984. The term certifying agency as used in this document means an
independent, not-for—proﬁt certifying agency or a not-for—proﬁt association with a certifying
component.

324

APPENDIX G 325

c. shall be administratively independent* in matters pertaining to
certiﬁcation, except appointment of members of the governing
body of the certifying agency. A certifying agency which is not a
legal entity in and of itself shall provide proof that the agency’s
governing body is administratively independent in certiﬁcation
matters from the organization of which it is a part;

d. shall have a governing‘body which includes individuals from the
discipline being certiﬁed. A certifying agency which certiﬁes more
than one discipline or more than one level within a discipline shall
have representation of each on the governing body;

e. shall require that members of the governing body who represent
the certiﬁed profession shall be selected by the certiﬁed profession
or by an association of the certiﬁed profession and such selection
shall not be subject to approval by any other individual or orga-
nization;

f. shall have formal procedures for the selection of members of the
governing body which shall prohibit the governing body from
selecting its successors;

g. shall provide evidence that the public consumer and the super—
vising professional and/or employers of the health professionals
have input into the policies and decisions of the agency, either
through membership on the governing body or through formal-
ized procedures as advisors to the governing body. This criterion
is effective january 1, 1981; and

h. the certifying body of a professional organization shall be separate
from the accrediting body of the professional association.

3. Resources of Certifying Agencies

a. shall provide evidence that the agency has the ﬁnancial resources
to properly conduct the certiﬁcation activities;

b. shall provide evidence that the staff possesses the knowledge and
skill necessary to conduct the certiﬁcation program or has available
and makes use of non-staff consultants and professionals to suf-
ﬁciently supplement staff knowledge and skill.

4. Evaluation Mechanism
a. shall provide evidence that the mechanism used to evaluate in-
dividual competence is objective, fair and based on the knowledge
and skills needed to function in the health profession;

*Administratively independent means that all policy decisions relating to certiﬁcation matters
are the sole decision of the certifying body and not subject to approval by any other body
and that all ﬁnancial matters related to the operation of the certifying component are seg-
regated from those of the professional association.

326

APPENDIX G

shall have a formal policy of periodic review of evaluation mech-
anisms and shall provide evidence that the policy is implemented
to insure relevance of the mechanism to knowledge and skills
needed in the profession;

. shall provide evidence that appropriate measures are taken to

protect the security of all examinations;

shall provide evidence that pass/fail levels are established in a man-
ner that is generally accepted in the psychometric community as
being fair and reasonable. This criteria is effectivejanuary l, 1981,
after standards are established; and

. shall provide evidence that the evaluation used evidence of at-

tempts to establish both reliability and validity for each form of
the examination.

5. Public Information

a.

C.

(1.

shall publish a document which clearly deﬁnes the certiﬁcation
responsibilities of the agency and outlines any other activities of
the agency which are not related to certiﬁcation;

shall make available general descriptive materials on the proce-
dures used in test construction and validation and the procedures
of administration and reporting of results;

shall publish a comprehensive summary or outline of the infor—
mation, knowledge, or functions covered by the test; and

shall publish at least annually, a summary of certiﬁcation activities,
including number tested, number passing, number failing, num—
ber certiﬁed and number recertiﬁed (if agency conducts a recer-
tiﬁcation program).

6. Responsibility on Applicants for Certiﬁcation or Recertiﬁcation

a.

C.

shall not discriminate among applicants as to age, sex, race, reli—
gion, national origin, handicap or marital status and shall include
a statement of non-discrimination in announcement of the certi-
ﬁcation program;

shall provide all applicants with copies of formalized procedures
for application for, and attainment of, certiﬁcation and shall pro-
vide evidence to the Commission that such procedures are uni—
formly followed and enforced for applicants;

shall have a formal policy for the periodic review of application
and testing procedures to insure that they are fair and equitable
and shall give evidence to the Commission of the implementation
of the policy;

shall publicize nationally appropriate data concerning certiﬁcation
program including eligibility requirements for certiﬁcation, basis
of examination, dates and places of examinations;

APPENDIX G , 327

6.

f.

shall provide evidence that competently proctored testing sites are
readily accessible in all areas of the nation at least once annually;
shall publicize nationally the specific education background or
employment backgound required for certiﬁcation;

shall give evidence that a means exists for individuals who have
obtained a skill or knowledge outside the formal educational set—
ting to be evaluated and obtain certiﬁcation or in the absence of
such means, provide reasonable justiﬁcation for exclusion. These
means employed should be consistent with the evaluation stan-
dards. The criterion is effective january 1, 1982;

shall provide evidence of uniformly prompt reporting of test re-
sults to applicants;

shall provide evidence that applicants failing the examination are
given information on general areas of deﬁciency;

shall provide evidence that each applicant’s test results are held
conﬁdential;

. shall have a formal policy on appeal procedures for applicants

questioning examination results and shall publish this information
in examination announcements; and

. shall have a formal policy, acceptable to the Commission, deline-

ating grounds, based on applicants prior or current conduct, for
refusing applicants eligibility to take the certiﬁcation examination
and shall provide applicants the opportunity to present their cases
to an impartial decisionmaker in the event of denial of eligibility
or denial of certiﬁcation. (Effective January 1, 1987)

7. Responsibilities to the Public and to Employers of Certiﬁed Personnel

a.

shall drive to insure that the examination adequately measures the
knowledge and skill required for entry, maintenance and/or ad—
vancement into the profession;

shall provide evidence that the agency awards certiﬁcation only
after the skill and knowledge of the individual has been evaluated
and determined to be acceptable;

. shall periodically publish a list of those persons certiﬁed by the

agency;
shall have a formal policy and procedure for discipline of certi-
ﬁcants, including the sanction of revocation of the certiﬁcate, for
conduct which clearly indicates incompetence, unethical behavior
and physical or mental impairment affecting performance that is
acceptable to the Commission. These procedures shall incorporate
due process (effective January 1, 1987);

any title or credential awarded by the credentialing body shall
appropriately reﬂect the practitioner’s daily occupational duties

328

APPENDIX C

and shall not be confusing to employers, consumers, health profes-
sionals and/or other interested parties (effective January 1, 1985);
The membership committee may consider the following factors
in determining whether practitioner’s titles or credentials comply
with this criterion:

(i) educational background;

(ii) function of profession;

(iii) occupational duties and breadth of these activities;

(iv) level of supervision by other practitioners, or of any other
practitioners; and

(V) various titles already in the ﬁeld, other titles considered,
and a justiﬁcation of why these titles were not utilized or
why they were changed.

8. Recertiﬁcation*

a.

b.

shall have in existence or shall be in the process of developing a
plan for periodic recertiﬁcation:

shall provide evidence that any recertiﬁcation program is designed
to measure continued competence or to enhance the continued
competence of the individual.

9. Responsibilities to Commission

21.

b.

shall provide the Commission on a regular basis with copies of all
publications related to the certifying process;

shall advise the Commission of any change in purpose, structure
or activities of the certifying agency;

. shall advise the Commission of substantive change in test admin-

istration procedures;

. shall advise the Commission of any major changes in testing tech-

niques or in the scope or objectives of the test; and
shall undergo re-evaluation by the Commission at ﬁve year inter-
vals.

*In this document the term recem'ﬁcation includes periodic renewal or revalidation of
certiﬁcation based on reexamination, continuing education, or other methods developed by
the certifying agency. This criterion is effective january l, 1982.

APPENDIX

 

Source Material

American Dietetic Association. 1972. The Profession of Dietetics: Report of the Study
Commission on Dietetics. Chicago: American Dietetic Association.

American Dietetic Association. 1985. A New Look at the Profession of Dietetics: Report
of the 1984 Study Commission on Dietetics. Chicago: American Dietetic Association.

American Medical Association. 1987. Allied Health Education Directory—1987. Chicago:
American Medical Association. ,

American Physical Therapy Association. 1979. The beginnings of “modern physiother-
apy." In The Beginnings: Physical Therapy and APTA. Washington, DC: American
Physical Therapy Association.

American Physical Therapy Association. Undated (ca. 1980). A Decision for Change.
Alexandria, Va.: American Physical Therapy Association.

American Society of Clinical Pathologists. 1987. Board of Registry Newsletter. March.

Biglow, L. A. 1982. Medical records education: An historical perspective. Journal of Amer—
ican Medical Records Association, August.

Burton, G. (3., and J. E Hodgkin. 1984. Respiratory Care, 2nd ed. Philadelphia: J. B.
Lippincott.

Coltey, R. W. 1978. Survey of Medical Technology. Chap. 1. St. Louis, Mo.: C. V. Mosby.

Corbett, F. R. 1909. The training of dietitians for hospitals. Journal of Home Economics,
1(62). Cited in American Dietetic Association. 1985. A New Look at the Profession
of Dietetics: Report of the 1984 Study Commission on Dietetics. Chicago: American
Dietetic Association.

Fay, M. 1979. Changing radiologic technology education: Evolution or revolution? Part
I. Radiologic Technology 50(6):667—673.

Fay, M. 1979. Changing radiologic technology education: Evolution or revolution? Part
II. Radiologic Technology 51(1).

Firestone, D. T., and C. Lehmann. In press. Changing roles for changing times. Journal
of Medical Technology.

Grunewald, L. R. 1928. The study of physiotherapy as a vocation. Part IV. The Physio-
therapy Review 8(5).

329

330 APPENDIX H

Hardwick, D. F., J. I. Morrison, and P. A. Cassidy. 1985 Perspectives in pathology: Clinical
laboratory—past, present, and future. An opinion. Human Pathology 16(3):206—21 1.

Hazenhyer, I. M. 1946. A history of the American physiotherapy association. The Phys-
iotherapy Review 26(1). Reprinted in American Physical Therapy Association. The
Beginnings: Physical Therapy and the APTA. Washington, D.C.: American Physical
Therapy Association.

Hopkins, H. L. 1983. An historical perspective on occupational therapy. In Willard and
Spackman’s Occupational Therapy, 6th ed., H. L. Hopkins and H. D. Smith, eds.
Philadelphia: J. B. Lippincott.

Ikeda, K. 1971. Twelve years of the registry. Cited in R. M. Williams. 1971. An Introduction
to the Profession of Medical Technology. Philadelphia: Lea 8c Febiger.

Journal of the American Medical Association. 1929/1971. Vol. 9211052. Cited in R. M.
Williams. 1971. An Introduction to the Profession of Medical Technology. Philadel—
phia: Lea & Febiger.

Karni, K. R., G. D. Price, and E. C. St. John. 1986. Perspectives in clinical laboratory
education. Journal of Medical Technology 3(2).

Laboratory Medicine. 1982. Professionals levels deﬁnition.Vol. 13(5):312—313.

Lanrose, N. 1983. Assessment and Intervention in Emergency Nursing. Bowie, Md.: R.
J. Brady. Cited in J. I. McKay. 1985. Historical review of emergency medical service,
EMT roles, and EMT utilization in emergency departments. Journal of Emergency
Nursing 11(1):27—-32.

Lunz, M. E. 1987. The impact of the quality oflaboratory staffon the accuracy oflaboratory
results. Journal of the American Medical Association 258(3):361—363.

Medical Record News. 1978. AMRA: The ﬁrst 20 years. August.

Motley, W. E. 1983. History of the American Dental Hygienists’ Associations. 1923—1982.
Chicago: American Dental Hygienists‘ Association.

Paden, E. P. 1970. A History of the American Speech and Hearing Association. Wash-
ington, D.C.: American Speech and Hearing Association.

Pennell, M. Y., and D. B. Hoover. 1970. Health Manpower Source Book—Section 21,
Allied Health Manpower, 1950—1980. Bethesda, Md.: National Institutes of Health.

Rockwood, C. A., C. M. Mann,J. D. Farrington, O. P. Hampton, and R. E. Motley. 1976.
History of emergency medical services in the United States.Journal of Trauma 16(4):299—
308.

Spahr, F. T. 1985. 1985 ASHA Directory Supplement. Rockville, Md.: American Speech—
Language—Hearing Association.

Torres, H. 0., and A. Ehrlich. 1976. Modern Dental Assisting, Chap. 1. Philadelphia:
W. B. Saunders.

U. S. Department of Commerce, Bureau of the Census. Statistical Abstracts of the United
States. 1987. Washington, D.C.: Government Printing Ofﬁce.

U. S. Department of Health, Education, and Welfare. 1979. A Report on Allied Health
Personnel. Washington, D.C.: Government Printing Ofﬁce.

Williams, R. M. 1971. An Introduction to the Profession of Medical Technology. Phila~
delphia: Lea & Febiger.

Index

A

Access to health care
scenario
general, 92—93
occupation-speciﬁc, 103, 113—
114,126—127,132,139, 145,
151
state regulatory restrictions, 240,
243, 246, 256—257
Accountants, 248—249
Accreditation, 18—19, 42, 182—183,
188
barriers to career promotion, 79—80
cardiovascular technicians, 40—41
dental hygienists, 23, 298
dietitians, 25
emergency medical technician
education, 27, 117
lab technicians, 22
perfusionists, 39
physical therapists, 30
private sources, 253, 254—255
radiologists, 35, 146
respiratory therapists, 36
speech—language pathologists and
audiologists, 38
statistics from accrediting bodies, 60
see also Committee on Allied Health
Education and Accreditation;

331

Professional associations and
societies
Administration on Aging, 277
Administrators, see Health care
administrators; Medical record
administrators and technicians
Aging and aged persons, see Elderly
AIDS, 68—70, 102, 124, 262 '
Allied health occupations
alternative ﬁnancing scenarios
general, 90—93
by occupation, 103, 113—114,
126—127, 131—132, 139, 145,
150—151
deﬁnitional issues
general, 1—3, 15—20, 41—42
occupation-speciﬁc, 20—41, 291—
295
included in study, criteria, 2, 19
metro—nonmetro population, 226
multiple competencies development,
220, 223, 229, 265—266
new fields, 38—41
public awareness of, 15
study approach, 1—4, 44—45, 59, 96,
283—284
supply/demand measurement, 44—
61, 63—94
by occupation, 96—153
see also specific occupations

332‘

Ambulance attendants, see Emergency
medical technicians
Ambulatory care, see Outpatient care
American Academy of Speech
Correction, 37
American Association for Respiratory
Care, 36, 143, 301
American Association of Medical
Record Librarians, 28
American Board of Cardiovascular
Perfusion, 39
American College of Physicians, 269—
270
American College Testing Program,
161
American Dental Association, 23,
243—244, 245—246
American Dental Hygienists’
Association, 23, 109, 243
American Dietetic Association, 19, 25,
111, 297
American Hospital Association, 49,
99, 118, 137, 223, 225—225
personnel supply/demand data, 297,
299, 300, 301
American Hospital Radiology
Administrators, 137
American Indians, 166, 167
American Medical Association
deﬁnition of allied health, 16
occupational therapy and, 30
American Medical Record Association,
28, 118, 299
American Occupational Therapy
Association, 30, 31, 124, 125,
189, 300
American Physical Therapy
Association, 32, 33—34, 60, 79,
130, 189,212,300
American Society for Medical
Technology, 104
American Society of Allied Health
Professions, 8, 15, 160, 261
American Society of Clinical
Pathologists, 298
American Society of Extra-Corporeal
Technology, 39
American Speech—Language—Hearing
Association, 37—38, 60, 147, 302
American Women’s Physical
Therapeutic Association, 32

INDEX

Applied Management Services, Inc.,
193

Area Health Education Centers, 168—
169, 277

Associate degrees, 83—84, 103, 109,
196, 211

Associations, see Professional
associations and societies

Astin, A. W., 171

Audiologists, see Speech—language
pathologists and audiologists

Automation, 77, 119, 120, 138

B

Begun, ]. W., 246
Biomedical Sciences Preparation
Program, 170—171
Blacks, 167, 170, 175, 218, 264
Blue Cross, 100
Blue Shield, 100
Boards, state regulatory, 241—242,
249—251, 255
Bureau of Health Professions, 3—4,
12, 178, 252, 256—257
dental care, 107, 297
lab technicians, 22, 300
needs projections, 53, 61
radiologists, 35
supply/demand data, 45—46, 76,
260—261
Bureau of Labor Statistics, on allied
health, 4
projections methodology and data,
54—57, 59—60, 61, 70—71, 73,
96—97, 307—310, 311—318
salaries and wages, 49—50, 212—214
supply/demand and characteristics,
25, 29, 37, 46, 54, 59, 85, 296—
302
Burnout, 117, 172, 173, 218, 219—220

C

California, 271—272
California Dental Association, 245
California Dental Association v. Office of
Statewide Health Planning and
Development et al., 245
Cardiovascular technology, 40—41
perfusionists, 39—40

INDEX

Career choice, 8, 163—165, 196, 218
employer role, 208—209
federal vocational guidance, 304
job mobility, 47, 220—221, 229, 247
minority access, 8, 169—175
nursing aides, 274
rural service, 227—228
salaries and, 214
see also Women’s career choices
Carpenter, E. 5,, 237, 253
Census Bureau, 50, 55, 65, 66—67,
225, 308
Center for Education Statistics, 4, 60,
82, 83—84
Center for Nursing Research, 191
Certiﬁcation, 18—19, 42, 252, 255
accountants, 248—248
cardiovascular technicians, 40—41
dental hygienists, 23
dietitians, 25
emergency medical technicians, 27,
298
federal guidelines, 252, 324—328
lab technicians, 22, 299
perfusionists, 39
physical therapists, 30
private sources, 252—253
radiologists, 35
respiratory therapists, 36
speech—language pathologists and
audiologists, 38, 302
by states, 238, 239
supply/demand and, 11—12
Children, 66—67
handicapped, 125, 126, 262
hearing impairments, 150
Chronic diseases, 70, 144, 230, 276;
see also Long-term care
Classiﬁcation of allied health
instructional programs, 291—295
Clearinghouse on Licensure,
Enforcement, and Regulation,
252
Clinical education, 176, 192—194, 195
Clinical laboratory personnel, see
Laboratory technologists and
technicians
College of Health Deans, 160
Commission on Dental Accreditation,
298
Committee on Allied Health

333

Education and Accreditation, 42,
176, 192
minorities, 167
occupation-specific activities, 16, 36,
39, 40
statistical data on supply/demand,
50, 60, 160, 161
women, 85
Committee on Nursing Home
Regulation, 264
Committee on the Cost of Medical
Care, 52
Committee to Study the Role of Allied
Health Personnel
study goals, methodology, themes,
and organization,
1—4, 44—45, 59, 96, 283—284
Community colleges, 83—84, 103, 109,
173,176,188, 198
Compensation, see Salaries and wages
Competition
among allied health turfs, 36, 126,
243
employer considerations,
206—207
job vacancies and, 48
other professionals and allied health
personnel, 78—79, 113
salaries, 209—210
see also Supply/demand, general;
Supply/demand, specific
occupations
Comprehensive Employment Training
Act, 180
Comprehensive Health Manpower Act
of 1973, 168
Computer-based technology, 77, 119,
120, 138
Consumerism, 113, 238, 249—250,
255
Cooperatives, 228
Cost containment, 93
dietitians, 112
physical therapists, 135
Sunrise provisions, 319—323
Council of State Governments, 247,
252
Court decisions, 245
Credentials, 235; see also Certification;
Licensure; State licensing
Cumulative Index of Nursing and

334

Allied Health Literature, 216
Current Population Surveys, 50, 59,
61, 82, 146, 316

D

Demographics, 7, 64, 65—68, 164,
217—218, 225, 261—262, 264
Demand, see Supply/demand, general;
Supply/demand, speciﬁc
occupations
Dental hygienists
deﬁnition and characteristics,
22—24, 291, 293, 297
education, 23, 109, 161, 196, 293
history, 23
licensure, 23—24, 297—298
research, 191—192
salaries, 24, 106
state regulation, 243—246
supply/demand, 106—110, 153,
297—298
Department of Education, 60, 309,
310
Department of Energy, 309
Department of Health and Human
Services, 12, 16, 26, 202, 252,
283—284
statistics, 4, 51, 53, 61, 202
Department of Health, Education,
and Welfare, 240, 247, 252, 256—
257
Department of Labor, 180, 310
Department of Transportation, 26,
180
Diagnostic testing, see Laboratory
technologists and technicians;
Radiologic technologists and
technicians
Dietitians, 254
alternative ﬁnancing scenarios,

113—1 14
deﬁnition of, 19—20, 24—26, 291,
297

education, 25—26, 114
history, 24—25
hospital employment, 110, 111, 297
licensure, 25
supply/demand, 6, 25, 110—115,
153, 297
Disabilities, see Handicapped persons

INDEX

Disease patterns, and allied health
demand
general, 68—70, 261—262
occupation-specific, 108, 125, 144,
150
Drugs, 102

E

Economic models, see Models
Economically disadvantaged, 168, 218,
304
Educational ﬁnance
clinical training, 192—194
federal funds, 8, 9, 87, 168,
178—180, 190, 192—193
minorities, 168
private funds, 9, 15, 169—171, 172,
182—183
state funds, 9, 87—88, 174,
180—182, 190
student investment, 197
supply/demand and, 86—88, 168,
173—174, 178—180, 189
Education, general, 2
accreditation, 253
applicant trends, 159—175, 188
associate degrees, 83—84, 103, 109,
196, 211
capacity maintenance and
expansion, 176—202,
221—222
classiﬁcation of instructional
programs, 291—295
clinical education, 176, 192—194,
195
college preparation, 171—172, 173—
174
cost of education, 194—195
employer role, 207, 208
enrollment trends, 82—84
faculty development, 188—192, 277
handicapped, 149, 274
hospital-based, 176, 192—194
in-service, 220, 228
labor force and, 7—9, 10
liberal education, 197—198
linkages with employers, 175, 188,
196, 197, 198—202,
227—229, 231
long—term care and, 13, 231,
232—233, 274—277

INDEX

Medicare support for, 180,
192—194

minority recruitment and retention,
8, 166—175,
171—172, 173—174

public information on state
regulation, 251, 326

recruitment, 163—166

retraining, 220

rural areas, 227—228

salaries and, 211, 213—214

statistics collection, 50, 52, 60

supply/demand and, 159—202, 221—-
222, 304—305

women, 81, 82—86; see also Women’s
career choices

see also Accreditation

Education of the Handicapped Act of

1986, 149

Education, speciﬁc occupations

cardiovascular technicians, 40

classiﬁcation of instructional
programs, 291—295

dental hygiene, 23, 109, 161, 196,
293

dental schools, 108

dietitians, 25—26, 114

emergency medical technicians, 26—
27, 117—118

lab technicians, 103, 104, 105, 160,
229, 293—294

medical record personnel, 28—29,
121, 122, 189

nursing aides, 274, 275—276

occupational therapists, 30,
127—128, 189

perfusionists, 39, 161

physical therapists, 33, 133—135,
160,161,176,189

radiologists, 34—35, 140, 141, 196

respiratory therapists, 36,
146—147, 196

social work, 162

speech—language pathologists and
audiologists, 38, 148, 150, 151,
152

see also Accreditation

Elderly

allied health demand, 65—66, 70,
274, 278

dietitians, 112

335

labor force demography, 218

long-term care of, 12—13,
260—261, 275, 276—278

occupational therapy, 125

physical therapy, 131

respiratory therapy, 144

women, 262, 264

see also Medicare; Nursing homes

Emergency medical technicians

deﬁnition, 26—27, 291, 298
education, 26—27, 117—1 18
history, 26

licensure, 27

privatization of services, 115—] 16
salaries, 116

supply/demand, 115-118, 298
volunteer, 27, 115, 116—1 17

Employers, 2, 4—5, 206—233

labor supply enhancement,
208—227

labor unions, 88—89, 220

linkages with educational
institutions, 175, 188, 196, 197,
198—202, 227—229, 231, 232—
233

long-term care, 230—231

productivity enhancement, 209,
214—215,221—224

recruitment role, 166

rural facilities, 225—229

salary/staff considerations,
206—207, 209—215, 222

staff tenure increases, strategies,
216—221, 222

see also Health care administrators;
Self—employment

Employment

burnout, 117, 172, 173 218,
219—220

macroeconomic model of, BLS, 54—
57, 90—91

see also Career choice; Labor
market; Part-time employment;
Salaries and wages; Self—
employment; Supply/demand,
general; Supply/demand,
speciﬁc occupations; Tenure;
Unemployment; Working
conditions

Epidemiology, see Disease patterns
Equipment and supplies, 143

336

Ethnic minorities, see Minorities
Extended care, see Long-term care

F

Facility administrators, see Health care
administrators
Faculty development, 188—192, 277
Family medicine, 190
Federal government, 202
deﬁnition of allied health, 16—17
educational ﬁnance, 8, 87, 178—180,
190, 192—194, 304
emergency medical services start—up
funding, 115
faculty development, 190
licensure and certiﬁcation and, 12
long-term care, role, 13
minority recruitment and retention,
168—169
monitoring of work force, 3—4
regulatory role, 251—252, 324—328
spending, 71, 168, 193, 304
see also Health Careers Opportunity
Program (HCOP); Medicare
Federal Industrial Rehabilitation Act,
30
Federal Trade Commission, 251
Fee-for-service, 91, 97
Finance, we Educational ﬁnance;
Health care ﬁnancing
Foundations, see Private foundations
Forum on Allied Health Data, 51, 61

G

Genetic technologies, 77

Geriatric Education Centers, 277

Geriatrics, see Elderly

GI. Bill, 35, 307

Gilmartin, M. E., 64

Goldstein, Harold, 55

Government, see Federal Government;
Licensure; Regulatory issues;
State governments; State licensing

Graduate Medical Education National
Advisory Committee, 53, 78—79

Gross national product, and labor
supply/demand, 55—56, 308

Grossman, jerome, 210

INDEX

H

Handicapped persons, 125, 126, 149,
262, 274
Health care administrators, 11, 206—
233, 269
labor supply enhancement, 208—
227
long-term care and, 13, 277—278
productivity enhancement, 209,
214—215, 221—224
rural facilities, 225—229
salaries and worker supply, 206—
207, 209—215, 222
staff shortages and, 206—207, 273—
274
staff tenure increases, strategies,
216—221
see also Medical records
administrators and technicians
Health care costs
allied health education, 194—195
dental, 107
hospital operating margins, 216
labor costs, 210, 214, 215
rehabilitation facilities, 271
state regulation and, 243, 246, 247,
248—249, 256—257
Sunrise provisions, 319—323
see also Cost containment
Health care delivery systems
alternative ﬁnancing scenarios
general, 90—93
by occupation, 103, 113—114,
126—127, 131—132, 139,145,
150—151
cooperatives, 228
productivity, 209, 214—215, 221—
224
rural, 225—229
unnecessary procedures, 223—224
see also Access to health care; Health
care facilities; Home care;
Long-term care
Health care facilities
regulation of, 238
rural, 225—229
Veterans Administration
rehabilitation facilities, 272—274
see also Hospitals; Nursing homes;
Rehabilitation facilities
Health care ﬁnancing
alternative scenarios

INDEX

general, 90—93
by occupation, 103, 113—114,
126—127, 131—132, 139, 145,
150—151
dentistry, 108—109
government, 8—9
home-based care, 64—65
long-term care, 262—263
mandated beneﬁts, 76
medical record services and, 28
occupational therapy, 125
physical therapy, 131
salaries of allied personnel, 209—
215
supply/demand for allied health
and, 74—76
see also Cost containment; Health
care costs; Insurance;
Prospective payment system
(PPS); Third-party payers
Health Care Financing
Administration, 65, 149, 180, 266
Health Careers Opportunity Program
(HCOP), 8, 168, 171—172, 173—
174, 175
Health maintenance organizations
(HMOs), 73, 92, 224 '
lab technicians and, 101
speech—language pathologists, 149,
150
Health planning agencies, statistical
responsibilities, 52
Health Professions Training Act of
1985, 168
Health Programs Extension Act of
1973, 168
Health promotion, 113
Health Resources and Services
Administration, 51—52, 104, 193
see also Bureau of Health
Professions
Health Training Improvement Act of
1970, 240
Hearing impairments, see Speech—
language pathologists and
audiologists
Highway Safety Act of 1966, 26
Hill Burton Act of 1946, 225
Hispanics, 166, 167, 218
Home care, 91, 274
long-term, 267—270
Medicaid, 268

337

Medicare, 64, 65, 75, 111, 130, 131,
149, 268, 269
occupational therapy, 124—125, 126
physical therapy, 131, 268
physicians, 269—270
prospective payment, 1 l 1
respiratory therapy, 63—65, 142,
143
speech—language pathologists, 149,
150
Hospitals, 5, 91
accreditation standards, 253, 254—
255
clinical education, 176, 192—194,
195
dietitians, 110, 111, 297
lab technicians, 98—100, 104
medical record personnel, 119, 299
multihospital systems, 73
occupational therapists, 123—124
operating margins, 216
physical therapists, 129—130, 131,
133
prospective payment system and,
75—76
radiology, 135—138, 139, 141,301
respiratory therapists, 141—142,
143—144, 146, 301
rural, 225—226
salaries of allied workers, 210, 215
speech—language pathologists, 149,
301—302
Hudson Institute, 165, 217—218
Human resources administrators, see
Health care administrators

I

Illinois, 181
Income, personal, effect on allied
health demand, 71, 108; see also
Salaries and wages
Information services, see Medical
record administrators and
technicians
Inhalation Therapy Association, 36
In-service training, 220, 228
Institute of Medicine (IOM), 45, 190,
231, 264, 266
Insurance, 71, 149—150
dental, 108
malpractice, 89—90
state-mandated benefits, 76

338

581? also Medicaid; Medicare; Third-
party payers
Intensive care units, 144
Internships, for dietitians, 114

J

job mobility, 47, 220—221, 229, 247

_]0b Partnership Training Act, 180

job placement, education-services
linkage, 175, 188, 196, 197, 198—
202, 227—229, 231, 232—233

job satisfaction, see Burnout; Working
conditions

job vacancies, as labor shortage
indicator, 47—48, 49

joint Commission on Accreditation of
Health Care Organizations, 253,
254—255

Josiah Macy Foundation, 169—171,
172

K

Kellogg Foundation, 15, 183
King, Elizabeth, 198—199

L

Laboratory technologists and
technicians
alternative ﬁnancing scenarios, 103
definition and regulation of, 20-22,
254, 291, 293—294, 298
education, 103, 104, 105, 160, 229,
293—294
history, 21
licensure, 22
salaries, 104
supply/demand, 5, 22, 98—105, 153,
271, 298—299
Labor market, 4—5
characteristics, 2, 18—19
general trends, 80—81
regulatory actions and, 11—12
see 060 Competition; Salaries and
wages; Supply/demand,
general; Supply/demand,
specific occupations;
Unemployment
Labor unions, 88—89, 220
Language pathologists, see Speech—
language pathologists and
audiologists

INDEX

Law, see Court decisions; Statutes
Librarians, see Medical record
administrators and technicians
Licensure, 18—19, 235—257
cardiovascular technicians, 40—41
dental hygienists, 23—24, 297—298
dietitians, 25
emergency medical technicians, 27
lab technicians, 22
occupational therapists, 30
perfusionists, 39
physical therapists, 33, 300
radiologists, 35, 139
respiratory therapists, 36
speech—language pathologists and
audiologists, 38, 148—149
supply/demand and, 11—12
see also State licensing
Local governments, 233, 310-311
Long-term care, 12-13, 259—278
administrators, 13, 277—278
deﬁnition, 260
dietitians, 111
employer issues, 230—231
occupational therapists, 126
see also Nursing homes
Long-Term Care Gerontology
Centers, 277

M

Make, B. J., 64
Malpractice, 89—90, 197, 238, 248
incompetence, 242
unnecessary procedures, 223—224
Mandated beneﬁts, 76
Marital status, 261
Market forces, sec Labor market;
Supply/demand, general; Supply/
demand, specific occupations
Medical record administrators and
technicians, 254
definition, 27—29, 118, 292
education, 28—29, 121, 122, 189
history, 28
salaries, 121, 162, 163
supply/demand, 29, 118—122, 299
Medicaid, 251, 268
respiratory therapy, 64—65
Medicare, 12, 71, 251, 252, 270—270
diagnostic tests and, 101

INDEX

education, support for, 180, 192—
194

emergency medical services, 117

home care, 64, 65, 75, 111, 130,
131, 149, 268, 269

nursing homes, 264, 266

occupational therapy, 124, 125, 126

physical therapy, 129, 130, 131

respiratory therapy, 143, 145

speech—language pathology, 149

see also Prospective payment system
(PPS)

Mental health, 230, 294; see also
Occupational therapists;
Psychiatric services

Mental retardation, 262

Minnesota, 247—249, 319—323

Minorities

demographics and allied health
demand, 67—68, 81, 218, 264
educational recruitment and
retention, 8, 169—175
Minority Access to Research Careers,
174
Minority Biomedical Research
Support, 174
Missouri, 182
Model programs, educational, 8, 201,
229, 275—276
Models
alternative financing scenarios
general, 90—93
by occupation, 103, 113—114,
126—127, 131—132, 139, 145,
150—151
educational costs, 194—195
education-services linkage, 201—
202, 229
nursing home teams, 265
projecting labor supply/demand,
52—54, 55, 91—93
Monthly Labor Review, 310
Mundinger, M., 268—269

N

National Academy of Sciences, 283—
284, 317

National Advisory Commission on
Health Manpower, 240

National Association for Home Care,
268

339

National Association of Rehabilitation
Facilities, 271
National Association of Teachers of
Speech, 37
National Certification Agency for
Medical Laboratory Personnel,
298—299
National Commission for Health
Certifying Agencies, 252, 324—
328
National Commission on Allied
Health Education, 15, 17
National Institute on Aging, 260—261
National Institutes of Health, 174,
191
National Occupational Information
Coordinating Committee, 310
National Research Council, 26
National Society for Allied Health,
166
National Society for Promotion of
Occupational Therapy, 30
National Task Force on Gerontology
and Geriatric Care Education in
Allied Health, 261
New England Medical Center, 210
New York State, 181
Nonproﬁt organizations, see Private
foundations
Nuclear medicine technologists, 136,
137, 300—301
Nurses and nursing, 190—191, 193,
231, 264, 268—269, 294
competition with allied health
personnel, 80
employment needs assessment, 53,
58
job satisfaction, 218—219, 220—221
linkage with allied health, 274
salaries and supply, 211, 271
Nursing aides, 19, 231, 265—267
education, 274, 275—276
Nursing Home Standards Committee,
266
Nursing homes, 73—74, 91, 230—231,
253, 260, 263—267
dietitians, 110
occupational therapists, 126
physical therapy, 130
quality control, 265—267, 274, 276
Nutrition, see Dietitians

340
0

Occupational Employment Statistics,
315—316, 317
Occupational Employment Survey, 60,
296, 311
Occupational health and safety, 131
Occupational Outlook Handbook, 307,
310, 217
Occupational therapists, 162—163, 272
alternative ﬁnancing scenarios,
126—127
definition, 29—31, 292, 299
education, 30, 127—128, 189
history, 29—30
licensure, 30
salaries, 31, 128, 271, 273
supply/demand, 31, 122—128, 271—
272, 273, 299—300
Omnibus Budget Reconciliation Act
of 1987, 101, 149,275
Organizational frameworks and
structures, 153
alternative ﬁnancing scenarios
general, 90—93
by occupation, 103, 113—114,
126—127, 131—132, 139, 145,
150—151
demand for services and, 72—74
home health care, 268—270
state regulation, 241—246, 249—251
Outpatient care, 101, 111; see alto
Home care
P
Part-time employment, 75, 76, 189,
230—231
dental hygienists, 107
dietitians, 297
physical therapists, 130, 230—231
Pathologists, sec Laboratory
technologists and technicians
Perfusionists, 39—40, 161—162
Personnel administrators, see Health
care administrators
Perry, Seymour, 77
Physical therapists, 162, 254, 273
alternative ﬁnancing scenarios,
131—132
definition, 31—34, 292, 300
education, 33, 133—135, 160, 161,
176, 189
history, 32
home care, 131, 268

INDEX

licensure, 33, 300
salaries, 34, 134, 135, 212, 271,
272—273
supply/demand, 4, 33, 128—135,
208, 271—272, 273, 300
Physicians
ambulance services owned by, 115—
116
home care, 269—270
lab technicians and, 100—101
nurses and, 219
supply of, 78—79
Poliomyelitis, 32—33
Political issues, educational support,
178, 181, 182
Poverty, see Economically
disadvantaged
Prediction, see Supply/demand,
general; Supply/demand, specific
occupations
Private foundations, 9, 15, 183, 202
minority recruitment and retention,
169—171, 172
rural health care, 229
Private sector, see Employers;
Professional associations and
societies; Self-employment
Privatization, emergency medical
services, 116—1 17
Productivity, employer role, 209, 214—
215, 221—224
Professional associations and societies,
232, 252—253
certifying agencies, federal
guidelines, 252, 324—328
deﬁnition of allied health
general, 17—18
by occupation, 297—301
educational responsibilities, 8, 183,
194—195
occupational recruitment incentives,
10, 166, 167
surveys and statistical data, 49, 50,
51, 60, 300, 302
see also individual associations and
societies
Professional qualiﬁcations, higher
education and, 189, 197, 200; see
also Certification; Licensure
Projections, sec Supply/demand,
general; Supply/demand, speciﬁc
occupatlons

INDEX

Prospective payment system (PPS), 91,
92, 268, 271
demand for allied health and, 75—
76, 97—98
dietitians, 111, 113
educational funding and, 193
emergency medical services, 117
employment patterns and, 5
lab technicians, 98—99, 100, 103
medical record occupations, 118,
120
occupational therapy, 124, 125, 126
physical therapy, 129, 132
radiology, 136—137, 139, 145
respiratory therapy, 64, 144
salary costs and, 215
speech—language pathologists and
audiologists, 150—151
Psychiatric services, 124
Public accountability, 251, 255
Public health, 112

Q

Quality control, 5, 102

education and, 161, 199—202

emergency medical services, 117—
118

medical records and, 119

nursing homes, 265—267, 274, 276

rehabilitative services, 274

state regulation and, 243, 245—247,
256—257

see also Accreditation; Certiﬁcation;
Licensure; Professional
qualiﬁcations; Regulatory
issues; Standards

R

Racial minorities, see Minorities
Radiologic technologists and
technicians
alternative ﬁnancing scenarios, 139
deﬁnition, 34—35, 292, 300
education, 34—35, 140, 141, 196
history, 34—35
hospital employment, 135—138,
139, 141, 301
licensure, 35, 139
salaries, 140—141
supply/demand, 34, 35, 135—141,
271, 300—301
Recordkeeping, see Medical record
administrators and technicians

341

Regulatory issues, 2, 18, 102, 235—257
federal role, 251—252
history, 236
labor force characteristics and, 11—
12
nursing homes, 266
private sector role, 252—253
quality of care, 5
state-level, 236—251
see also Accreditation; Licensure;
Standards; State licensing
Rehabilitation facilities, 270—274, 295
Report on Allied Health Personnel, 16
Report on Licensure and Related
Health Personnel Credentialing,
240
Research
academic, 184, 190—192
on career choice and development,
163
committee study goals,
methodology, themes,
organization, 1—4, 44—45, 59,
96, 283—284
data limitations, 3—4, 45—46, 50—52,
59—61, 296
dissemination of ﬁndings, 10, 232
on effectiveness of speciﬁc
professions, 224, 232
on employee retention, 219—220
ﬁnancial support of, 9
minority opportunities, 174
on nursing, 190—191
on personnel policies, 231, 232
on regulation, 251
on supply/demand, 305—310, 311—
314, 319—320
see also Bureau of Labor Statistics;
Statistical programs and
act1v1t1es
Respiratory therapists, 255
alternative ﬁnancing scenarios, 145
deﬁnition, 35—37, 292, 301
education, 36, 146—147, 196
history, 36
home care, 63—65, 75
hospital employment, 141—142,
143—144, 146, 301
licensure, 36
salaries, 146
supply/demand, 6, 37, 63—65, 141—
147, 153, 208, 271,301

342

Retraining, 220

Robert Wood Johnson Foundation,
169, 229

Rural health care facilities, 225—229,
273

S

Salaries and wages, 2, 10, 230—232,
274
dental hygienists, 24, 106
employer considerations, 206—207,
209—215, 222
lab technicians, 104
labor shortage indicator, 48
medical record personnel, 121, 163
nurses, 211, 271
nursing aides, 266—267
occupational therapists, 31, 128,
271, 273
perfusionists, 162
physical therapists, 34, 134, 135,
212, 271, 272—273
radiologists, 140—141
respiratory therapists, 146
social workers, 162
speech—language pathologists and
audiologists, 38, 152
Selden, 250—251
Self—employment
complex medical settings and, 221
dietitians, 110—1 11
physical therapists, 130—131, 212
social work, 162
speech—language pathologists and
audiologists, 150, 301
Sex discrimination, salaries, 212
Shimberg, B., 238
Social work, 162
Societies, see Professional associations
and societies; and individual
associations and societies
Society of Diagnostic Medical
Sonographers, 41
Southern Educational Research
Board, 197
Southern Illinois University, 229
Specialization, 196, 197; see also specific
allied health proﬁssions
Speech—language pathologists and
audiologists

INDEX

alternative ﬁnancing scenarios,
150—151
deﬁnition, 37—38, 148, 292, 301
education, 38, 148, 150, 151, 152
hospital employment, 149, 301—302
licensure, 38, 148—149
research, 192
salaries, 38, 152
supply/demand, 6, 38, 147—152,
153, 271, 301—302
Standards, 252, 266
state-level, 238—239
see also Accreditation; Licensure
State governments
boards, regulatory, 241—242, 249—
251, 253, 255
cost, quality, access, and regulation,
240, 243, 245—247, 248—249,
253, 255
dental hygienists, regulation, 243—
246
educational ﬁnancing, 9, 87—88,
174,180—182, 190
education-service linkages, 201—
202, 232—233
mandated insurance benefits, 76
minority recruitment and retention,
169, 174
regulatory powers, 236—251, 252
Sunrise procedures, 247—249, 255,
319—323
supply/demand data, 310—311
State licensing, 200, 202, 236—238
criticisms, 240—249, 253
deﬁnition, 237—238
dental hygienists, 23—24, 297—298
dietitians, 25
emergency medical technicians, 27
history, 236, 238
lab technicians, 22
occupational therapists, 30
physical therapists, 33, 300
radiologists, 35, 139
reforms, 247—251, 255—257
respiratory therapists, 36
speech—language pathologists and
audiologists, 38, 148—149
statistics, 52
Sunrise procedures, 247—249, 255,
319—323
Statistical programs and activities

INDEX

data limitations, 3—4, 45—46, 50—52,
59—61, 296
education, 4, 60, 82, 83—84, 85, 180
emergency services, 118
federal government, 3—4, 304—310;
see also Bureau of Labor
Statistics
job vacancy data, 4
salary and wage data, 49—50
state and local efforts, 310—311
supply/demand data, 45—46, 50—52,
58—61
projections purpose and
methodology, 303—318
see aLw Demographics; Medical
record administrators and
technicians
Statutes
certification, 255
Comprehensive Employment
Training Act, 180
Comprehensive Health Manpower
Act of 1973, 168
dental hygiene, 244
Education of the Handicapped Act
of 1986, 149
Federal Industrial Rehabilitation
Act, 30
GI. Bill, 35, 307
Health Professions Training Act of
1985, 168
Health Programs Extension Act of
1973, 168
Health Training Improvement Act
of 1970, 240
Highway Safety Act of 1966, 26
Hill Burton Act of 1946, 225
job Partnership Training Act, 180
licensure, 11—12, 241
occupational therapy, 125
Omnibus Budget Reconciliation Act
of 1987, 101, 149, 275
Sunrise procedures, 247—249, 255,
319—323
Structural issues, see Organizational
frameworks and structures
Student aid, 174, 180
Study Commission on Dietetics, 25
Substance abuse, 102
Sunrise procedures, 247—249, 255,
319—323

343

Supply/demand, general, 44—61, 63—
94, 152—153, 296—297
AIDS, 68—70, 102, 124, 262
alternative ﬁnancing scenarios
general, 90—93
by occupation, 103, 113—114,
126—127, 131—132,139, 145,
150—151
current situation, 46—52
data available, 45—46, 50—52, 59—61
demography and, 65—68
economic growth and, 70—72
educational sector, effect on, 7—9,
82—88, 176—202
employers‘ role, 9—1 1, 206—233
estimation methodology, 3—5, 54—
57, 305—310, 311-314
ﬁnancing of health care and, 74—76
future
general, 5—6, 52—61
by occupation, 96—153
industry structure and, 72—74
licensure, certification, accreditation
and, 11—12
long-term care, 230—231, 278
malpractice, 89—90
other health professionals and, 78—
80, 113
productivity issues, 209, 214—215,
221—224
projections, methodology and uses,
303—318
rural areas, 225—229
salary and, 209—215
shortages
indicators, 47—49
strategies for remediation, 210—
211, 273—274
state and local projections, 310—311
unions, 88—89, 220
Supply/demand, specific occupations,
96—153, 296—302
alternative ﬁnancing scenarios, by
occupation, 103, 113—114,
126—127,131—132,139,145,
150—151
dental hygienists, 106—110, 153,
297—298
dietitians, 6, 25, 110—115, 153, 297
emergency medical technicians,
115—118, 298

344

lab technicians, 5, 22, 98—105, 153,
271, 298—299

medical record personnel, 29, 118—
122, 299

occupational therapists, 31, 122—
128, 271—272, 273, 299—300

physical therapists, 4, 33, 128—135,
271—272, 273, 300

radiologists, 34, 35, 135—141, 271,
300—301

respiratory therapists, 6, 37, 63—65,
153, 208, 271, 301

speech—language therapists and
audiologists, 6, 38, 147—152,
153,271, 301—302

Surveys, see Statistical programs and
activities

T

Technical assistance, 10
statistics, 51—52
Technicians, see Emergency medical
technicians; Laboratory
technologists and technicians;
Radiologic technologists and
technicians
Technological innovation, 6, 18, 91—
92, 108, 255
demand for allied health and, 76—
78
dietitians, 111
emergency medical services, 116—
117
lab technicians, 98, 100, 102
productivity and, 222
radiology, 135, 137—138, 139
respiratory therapy, 64, 142
Tenure, 200
employers‘ strategies for increasing,
216—221
supply/demand for labor and, 9,
134
Texas, 181, 182, 196, 208—209
Therapists, see Occupational
therapists; Physical therapists;
Respiratory therapists
Third-party payers
clinical education, 8
demand for allied health and, 75
occupational therapists, 30
social work, 162
state certiﬁcation and eligibility, 12

INDEX

see also Insurance; Medicaid;
Medicare; Prospective payment
system (PPS)
Torts, malpractice, 89—90, 197, 238
Training, see Education, general;
Education, specific occupations

U

Unemployment, 165, 304
factor in demand for allied health,
71
as labor shortage indicator, 48—49,
50
Unions, see Labor unions
University of Alabama, 227—228, 229
University of Wisconsin, 229
Unnecessary procedures, 223—224

V

Vascular technicians, see
Cardiovascular technology

Veterans, 35, 180

Veterans Administration, 180, 272—
274, 277, 307

Volunteer emergency medical
technicians, 27, 115, 116—117

W

Wages, see Salaries and wages
Western Interstate Commission on
Higher Education, 53
Women, elderly, 262, 264
Women’s career choices, in allied
health labor force, 2, 160, 165,
218
American Women’s Physical
Therapy Association, 32
dietitians, 25
education, 81, 83—86
lab technicians, 22
medical records personnel, 29
radiologists, 35
and salaries in labor force, 212, 215
Working conditions, 218—219, 219,
222, 230—231, 267
burnout, 117, 172, 173, 218, 219—
221
Workmen’s compensation, 131

X

X rays, see Radiologic technologists
and technicians

   
 

UV—

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