Overview of spending and employment trends in health care and long-term care

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1 Overview of spending and employment trends in health care and long-term care David I Auerbach, PhD Adjunct Faculty, Montana State University Director of Research, Massachusetts Health Policy Commission April 10,

2 Two perspectives on long-term care workforce Two perspectives Occupational perspective Industry perspective Variation over time and by US region 2

3 The health care workforce in 2016 Physician Assistants $101k Nurse Practitioners $108k Educational level PT $85k Physicians $220k Pharm $122k Master s/doctoral Lab Tech $51k Registered Nurses ($68k) Lic Pract Nurse ($44k) Associate s / Bachelor s Home Health and personal care aides ($22k) Nursing aides ($27k) Med asst ($32k) High School + Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million. Sources: Bureau of Labor Statistics,

The health care workforce in 2016 Physician Assistants $101k Nurse Practitioners $108k Educational level PT $85k Physicians $220k Pharm $122k Master s/doctoral Lab Tech $51k Registered Nurses ($68k)

4 The health care workforce in 2016 Physician Assistants $101k Nurse Practitioners $108k Educational level PT $85k Physicians $220k Pharm $122k Master s/doctoral Lab Tech $51k Registered Nurses ($68k) Lic Pract Nurse ($44k) Associate s / Bachelor s Home Health and personal care aides ($22k) Nursing aides ($27k) Med asst ($32k) High School + Note: Areas are proportional to number of workers with each job title. Combined workers total ~10 million. Sources: Bureau of Labor Statistics,

5 Number of RNs (FTE) under age , , , , , , Authors analysis of workforce data from the Current Population Survey. FTE based on a 40-hour workweek. 5

6 Millennial RNs are projected to far surpass the peak numbers of baby boom RNs 2,500,000 2,000,000 1,500,000 1,000, , Number of Registered Nurses Employed on A Full-Time Basis by Generation: Historical and Projected baby boomers (actual) Gen X (actual) Millenials (actual) baby boomers (forecast) Gen X (forecast) Millenials (forecast) Pre-boomers (actual) Auerbach, David I., Peter I. Buerhaus, and Douglas O. Staiger. "Millennials Almost Twice As Likely To Be Registered Nurses As Baby Boomers Were." Health Affairs (2017) 6

7 Students taking the NCLEX exam doubled 180,000 Number taking the NCLEX exam 160, , , ,000 80,000 Total Domestic, first-time ADN BSN 60,000 40,000 20, Authors analysis of data from National Council of State Boards of Nursing 7

8 Associate-degree RNs are shifting from hospital to long-term care sector 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% % in hospital % in hospital % in long-term care % in long-term care Hospital Long-term Care % of FTE RNs by employment setting by year: American Community Survey 8

9 Physician supply has grown much more slowly than RN supply Number of professionals per 10,000 US population RNs Physicians PAs NPs US Decennial Census and American Community Survey 9

10 Physician supply has not kept pace with health spending % increase Real health spending per capita $3,354 $9, % Health care spending as % of GDP 8.9% 17.7% 99% RNs per capita % Physicians per capita % 200% % increase, % 0% Real health spending per capita Health care spending as % of GDP RNs per capita Physicians per capita Health care spending adjusted by CPI to 2015 dollars 10

11 Barriers to entry in the physician market Residency is required to practice in the US The number of positions is jointly determined by hospitals and specialty societies (residency review committees) along with a national accrediting body RRCs may limit slots, acting as a guild Minimum patient volume requirements and hospitals financial interests may also limit slots Nicholson, Sean. Barriers to entering medical specialties. No. w9649. National Bureau of Economic Research,

12 Other clinicians will likely fill some of the gap Physician assistants (PA), nurse midwives (NM), nurse practitioners (NP) and nurse anesthetists (NA) Typically 2-3 years educational requirements beyond baccalaureate degree (more NPs earning doctorates) Earnings are roughly half of physicians Considerable overlap with physician-provided care AAMC high assumptions for reduction in physician demand: anesthesiology (60%), women s health (40%), primary care (50%), medical specialties (30%), surgery (20%), and other medical specialties (30%). Scope of practice authority is increasing Education is expanding (282 NP programs in 2000; 424 in 2016) 12

13 Most added practitioners between 2015 and 2030 will be NPs and PAs 100,000 physicians 100,000 NPs 100,000 PAs Historical data based on Analysis of survey data from the US Census Bureau and the National Sample Survey of RNs. Projections based on workforce supply model. Publication of results is forthcoming (proj) 13

14 The base of the pyramid Home health and other aide jobs tend to be low-skill, minimum-wage, high-turnover with little mobility. From a recent Massachusetts study*: Agencies, on average, hired 18 workers over a three month period and lost 15 workers Home care agencies reported a quarterly home care aide turnover rate of 16% Nearly 90% of the agencies indicated that recruiting qualified home care aides was their top workforce challenge Over 47% of the aides who responded to our survey have at least one other job 40% live in households with an annual income of less than $20, % were Medicaid recipients Nearly 50% were born outside the US *Home Care Aide Council, Setting the agenda: Data-driven advocacy to address home care aide policy, Tufts Health Plan foundation,

15 Long-term care sector view CMS National Health Expenditures How is spending shifting by sector and site of care? Bureau of Labor Statistics How is employment in these sectors shifting (through 2017)? American Community Survey How does employment in the long-term care sector differ by region, by occupation, and over time? 15

16 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% National Health Expenditures by category (%), Hospitals Nursing Facility, and Continuing Care Administrative Physician and Clinical + Other professional Other Health Care, DME and drugs Home Health Care Source: CMS National Healthcare Expenditures 16

17 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 Hospital spending per resident, ,337 2,351 2,376 2,446 2,617 2,625 2,673 2,698 2,703 2,732 2,739 2,753 2,764 2,779 2,807 2,817 2,833 2,912 2,915 2,933 2,940 2,964 3,038 3,050 $3,079 3,090 3,118 3,166 3,217 3,228 3,256 3,283 3,292 3,326 3,373 3,380 3,416 3,431 3,433 3,491 3,492 3,492 3,492 3,502 3,617 3,633 3,722 3,771 3,780 3,809 3,933 3,953 4,001 4,037 4,078 4,415 4,479 4,670 4,715 5,233 Arizona Utah Nevada Georgia Tennessee Alabama Arkansas Texas Southwest Florida Colorado California Hawaii North Carolina Southeast Far West Rocky Mountains Virginia New Jersey South Carolina Oregon Kansas Idaho Louisiana United States Washington Oklahoma New Mexico Kentucky Mississippi Michigan Maryland Iowa Connecticut Minnesota Illinois Pennsylvania Plains Mideast Great Lakes Indiana Missouri Nebraska Wisconsin Rhode Island New York Montana New Hampshire New England Ohio Massachusetts Maine Wyoming West Virginia Delaware South Dakota North Dakota Vermont Alaska District of Columbia Home care spending per resident, 2014 $800 $700 $600 $500 $400 $300 $200 $100 $ $ North Dakota Wyoming South Dakota Nebraska Arizona Kansas Montana Virginia Kentucky Indiana Georgia Hawaii Oregon Iowa Maryland Idaho Rocky Mountains Arkansas Utah Washington Colorado North Carolina Oklahoma Alaska Alabama Maine Mississippi Tennessee Illinois Southeast South Carolina Missouri New Hampshire Wisconsin Nevada Great Lakes Delaware New Jersey Pennsylvania Southwest New Mexico Rhode Island Ohio Far West United States Plains West Virginia Texas Louisiana Michigan California Florida Connecticut Vermont Mideast New England New York Minnesota District of Massachusetts 17

18 Percent growth in employment by sector 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Social Assistance (Ind/fam serv, comm food housing, voc rehab, child day) Ambulatory care (office of phys, dent, oth; outpatient, lab, home health) Hospital (general, specialty, psych) Nursing and res care (nursing fac, mental health and subs abuse fac, comm care for elders, oth) Source: BLS Current Employment Statistics. Data points represent total employment in May of each year shown 18

19 Total employment in long-term care by region, 2015 TOTAL EMPLOYMENT BY SECTOR PER 10,000 RESIDENTS Northeast Midwest South West HOME HEALTH NURSING FACILITY RESIDENTIAL CARE ALL Source: American Community Survey data based on 1% sample 19

20 Employment per 10,000 in nursing facilities and residential care, by region, 2000 and Nursing facility Residential care Northeast Midwest South West Source: American Community Survey data based on 1% sample 20

21 Distribution of employment by LTC sector, % 50% 40% 30% 20% 10% 0% New England Middle Atlantic South Atlantic East South Central West South Central East North Central West North Central Mountain Pacific Residential care Home Health Nursing Facility Source: American Community Survey data based on 1% sample 21

22 Occupational mix in home health sector Pacific Division 16.8% 45.5% 20.2% 10.8% 6.7% Mountain Division 20.1% 34.3% 29.4% 11.5% 4.7% West South Central Di 23.1% 28.5% 31.8% 9.2% 7.3% East South Central Di 24.9% 26.6% 28.4% 13.7% 6.4% South Atlantic Divisi 22.8% 17.6% 38.9% 12.9% 7.7% West North Central Di 18.4% 26.9% 35.7% 12.1% 7.0% East North Central Di 20.1% 24.3% 39.5% 10.0% 6.0% Middle Atlantic Divis 14.3% 13.9% 56.5% 9.0% 6.2% New England Division 25.4% 19.2% 38.7% 12.8% 3.8% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% other personal care aide nursing aide RN LPN Source: American Community Survey data based on 1% sample 22

23 Occupational mix in residential care sector Pacific Division 26.4% 6.9% 1.9% 2.9% Mountain Division 23.2% 12.9% 1.6% 2.1% West South Central Di 22.5% 11.0% 0.7% 2.9% East South Central Di 20.2% 13.0% 2.6% 8.6% South Atlantic Divisi 14.6% 11.5% 3.2% 3.9% West North Central Di 23.6% 13.0% 2.2% 3.2% East North Central Di 23.4% 11.8% 2.9% 4.1% Middle Atlantic Divis 17.3% 7.9% 4.3% 3.7% New England Division 15.9% 13.1% 3.6% 2.2% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% personal care aide nursing aide RN LPN Source: American Community Survey data based on 1% sample. Other is the remaining category (not shown) 23

24 Conclusions from American Community Survey There is remarkable variation in mix of sectors within long-term care The West employs a similar sized workforce in home health, residential care, and nursing facilities In the Midwest, the ratios are 1:1:2, with double overall employment per capita The East is like the Midwest, but with more Home Health, and the South is generally in between Residential care employment has nearly doubled while nursing facility employment has held constant Personal Care Aides (PCA) and nursing care aides appear substitutable the West uses far more PCAs than everyone else 24

25 Country/region of birth (excluding US) by occupation for those working in long-term care, % 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% other Pers Care Assistants Nursing Assistants RN LPN Mexico/Central AM West Indies South AM Phillippines Africa Other Source: American Community Survey data based on 1% sample 25

26 Country/region of birth (excluding US) for all workers in residential care or nursing facilities, 2000 and % 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Nursing Facilities Nursing Facilities Residential Care Residential Care Mexico/Central AM West Indies South AM Phillippines Africa Other Source: American Community Survey data based on 1% sample 26

27 Geriatric Workforce in Nursing and Medicine Karen Donelan, ScD, EdM Associate Professor, Harvard Medical School Senior Scientist in Health Policy, Massachusetts General Hospital April 10, 2018

28 U.S. Popula+on, Adults 65+ and ,344, ,813,596 (millions) ,451,393 1,081,760 34,991,753 4,175,000 5,493,433 6,304,000 14,634, Ages 65+ Ages 85+ Source: U.S. Bureau of the Census 25-50% frail

29 Hospital Stay in Past 12 months, Adults % 20% 22.8% 20.3% 15% 10% 17.9% 13.9% 5% 0% years 75 years and over Source: Health, United States (National Health Interview Survey)

30 Percentage of beneficiaries using home health care, by characteris+c, 2010 Kaiser Family Founda+on Analysis of Medicare Current Beneficiary Survey

31 Nursing Home Popula+on 1,600,000 1,400,000 1,200,000 1,000, , , , , ,503,000 1,280,000 1,368, , Adults 65+ Source: CDC, NCHS

32 Adults 65+ Served by Hospice 1,800 1,600 1,656,000 1,400 1,200 1, , , Source: National Hospice and Palliative Care Organizatio n

33 PracCce LocaCons Primary Care: All Ages Primary Care for Seriously Ill Senior Health, Geriatric Care Care Management Residential Care, Assisted Living Nursing Home Care Home Health Mobile Health

34 NURSING DR. JENNIFER KIM AND DR. LINDA NORMAN, VANDERBILT UNIVERSITY SCHOOL OF NURSING

35 EvoluHon of Gerontological Nursing 1960s: American Nurses Association (ANA) forms Division of Geriatric Nursing 1970s: Certification for Gerontological RN & Gerontological Nurse Practitioner first available 1970s: ANA publishes first edition of Standards for Gerontological Nursing Practice 1980s: R.W. Johnson funds Teaching Nursing Home (TNH) programs 1980s: NGNA & NCGNP organizations form 1980s: ANA publishes Scopes & Standards of Gerontological Nursing Practice 1990s: NICHE & HIGN are created 1990s: APRNs receive direct reimbursement from Medicare for services provided 1990s: Evercare demonstration project 2000s: AACN publishes older adult competencies for BSN and MSN programs 2008: AACN endorses Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, & Education (LACE). 2012: Certification for Adult/Gerontology APRNs available 2015: GAPNA Consensus Statement on Proficiencies for the APRN Gerontological Specialist 2018: New Certification Launches March, 2018 with focus on complex, chronic illness

36 What is a Gerontological RN? 1 N= 7,891 (< 1%) Degree requirement for entry to praccce: Diploma, ASN, BSN CerCficaCon through the ANCC Average # of years RN experience= 26 31% work in LTC; 35% BSN & 28% ASN Unique Skills: o Geriatric assessment skills o IdenCficaCon & prevencon of geriatric syndromes o Geriatric-sensiCve pacent advocacy o Individualize plan of care

37 What is a Gerontological APRN? < 3% of all APRNs (< 7% of adult/gerontology) Minimum degree requirement for entry to praccce: MSN CerCficaCon through the ANCC &AANP Most gerontological NPs praccce in LTC facilices Unique Skills: o Training & educacon solely in geriatrics o Advanced geriatric assessment skills o Management of medical and psychosocial needs of frail older adults o IdenCficaCon, management, & prevencon of geriatric syndromes o Coordinate interprofessional teams o Educate LTC staff members

38 Beyond Specialty: NPs Caring for Older Adults Na#onal Survey of NPs *Primary Care

39 NPs Caring for Older Adults 3 of 4 NPs are accephng new Medicare pahents 8 NPs are predominant providers of care for older adults: o Long term care 12 o Medicare beneficiaries with demenca 13 o Residence-based care 14 Improved clinical outcomes with NPs (fewer hospitalizacons & rehospitalizacons of nursing home residents managed by NPs) 12 Nursing home with NPs and PAs on staff is associated with higher Medicare 5-star rahng. 12 Sources AANP National Nurse Practitioner Sample Survey 2. Fang, D., Li, Y., Kennedy, K.A., & Trautman, D.E. (2017) Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington DC: AACN 3. Yang, M., Chigan-Hua, C., Carmichael, D., Oh, E., & Bynum, J. (2016). Who is providing predominant care for older adults with dementia? Journal of the American Medical Directors Association, 17(9); Yao, N., Rose, K., LeBaron, V., Camacho, F., & Boling, P. (2016). Journal of the American Geriatrics Society, 65,

40 Gerontological Nursing Challenges Few faculty with gerontological nursing expertise Few mentors NP practice restrictions- Impact on patient care Lack of interest in geriatrics Few RNs providing bedside care in SNFs and NHs Changes in RN and APRN training- enough geriatrics?

41 Areas of Progress NHCGNE: Development of core competencies for gerontological nurse educators 2007: Geriatric Academic Career Award (GACA) for doctorally prepared nurses cercfied in geriatrics Gerontological Advanced PracCce Nurses AssociaCon (GAPNA) and Society for Post-Acute and Long-Term Medicine (AMDA) form partnership in 2016; membership growing

42 MEDICINE DR. SHARDA MUKUNDA, MASS GENERAL

43 Medical Licensure

44 Total AcCve Physicians 120, , , ,000 80,000 60,000 40,000 20, ,227 6,400 13,392 Family Med/GP Internal Med Geriatric Med PalliaCve Care Neurology Total AcCve Physicians Sources:

45 History of Geriatrics as a Medical Specialty Term coined in early 1900s by Nasher. Published a book in 1914, Geriatrics: The Diseases of Old Age and Their Treatment Great Depression- Increase in elderly poor (30% 1930; 66% 1940) Medicare, Medicaid established which increased interest and funding for caring for older adults The first Geriatrics Fellowship was in 1966 at Mt.Sinai

46 What is a Geriatrician? Leipzig, Rosanne M., et al. "What Is a Geriatrician? American Geriatrics Society and AssociaCon of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional AcCviCes for Geriatric Medicine." Journal of the American Geriatrics Society 62.5 (2014): Internal medicine and family praccce residency, completed geriatrics fellowship Comprehensive geriatric assessment and management Integrate goals and values, prognosis, comorbidices into decision making Facilitate goals of care discussions and end of life care Manage geriatric syndromes Prevent polypharmacy and aid in medicacon review Interprofessional and collaboracve expert

Geriatric Fellowship Programs NRMP Match Data: http://www.

47 Geriatric Fellowship Programs NRMP Match Data: SMS-2017.pdf

48 Filled and Unfilled Fellowship PosiHons NRMP Match Data: SMS-2017.pdf

49 Reproduced with permission from Kevin Foley, Michigan State University, and Carrie Rubenstein, Swedish Medical Center Diminishing Numbers of Geriatricians AMA and AAMC data from National Survey of GME Programs, JAMA Fewer Geriatricians are being trained:

50 Residency/Fellowship Fill Rate 100% 90% 95.8% 98.2% 89.0% 97.4% 80% 70% 60% 50% 44.5% 40% 30% 20% 10% 0% Family Med/GP Internal Med Geriatric Med (fellowship) PalliaCve Med (fellowship) Neurology % Filled Source:

51 Comparison of career net income between an adult-gerontology primary care nurse prachhoner and a geriatrician at 65 years of age (age 22-65, no undergrad debt, all med school financed) Variables Career net earnings, $ Percentage difference Break-even age, y Current system Nurse praccconer 6,842,476 Geriatrician 8,937, Primary care physician 9,525, Policy intervencons School loan remimance 9,878, Nonfellowship geriatric cercficacon Emanuel educacon mode, school loan remimance 9,244, ,079, Emanuel educacon mode, school loan remimance, nonfellowship geriatric educacon 11,344, Golden AG, Xu P, Wan TT, Issenberg SB EsCmaCng the Net Career Income of a Geriatrician and a Nurse PracCConer: SCll Want to be a Doctor? Southern Med J, July 2016.

52 Things to Watch For. HRSA: Geriatric Workforce Enhancement Projects 44 organizacons 29 states $35.7 million investment in primary care and geriatric care Standard Measurement and New Tools NLN Advancing Care Excellence for Seniors New models developed with increased recognicon PACE Hospital Elder Life Programs Increased recognicon of geriatric syndromes as important areas of research Falls, frailty, sarcopenia to name a few Payments from the Centers for Medicare and Medicaid Services Annual Wellness Visits, Chronic care management, Home visits, Advance care planning, TransiConal care, Readmissions policies

53 Private Investment in New Care Models Iora: 127 million (Series A,B,C,D) different care models in primary care, recent Medicare Advantage, health plan and employer sponsors Devoted: 62 million (Series A,B) (Athena, Sibelius, Frist) Medicare, Tech focus Cityblock Health: 23.2 million (Series A) (Slavim, Conway, Molina): urban health, Medicare and Medicaid Oak Street (private): Medicare Advantage, primary care deserts One Medical: 117 million: primary care redesign, all ages, 2013 Startup of the Year

54 Conclusions Tremendous demand ahead ExpectaCon of unmanageable costs how to bend the cost curve? Licensed and unlicensed professionals needed, as well as best models Primary care shortages in many areas of the US, and yet it is assumed they can manage a large share of this increasing load Many pressures to care for older adults outside of the hospital Inadequate supply of geriatric providers though some disagree that we need more How can we best deploy those with more specialized training? How can we provide incencves for nurses and physicians to enhance their expercse and pursue specializacon?

Percentage of Enrolled Students by Program Type, 2016

Percentage of Enrolled Students by Program Type, 2016 Doctorate 4% PN/VN 3% MSN 15% ADN 28% BSRN 22% Diploma 2% BSN 26% n = 279,770 Percentage of Graduations by Program Type, 2016 MSN 12% Doctorate 1%