The Northwest Minnesota Health Professions Study: An Analysis
The Northwest Minnesota Health Professions Study: An Analysis -
Development and publication of this analysis sponsored by: University of Minnesota Vice Provost, Distributed Education and Instructional Technology Office of the Executive Vice President and Provost Academic Health Center Analysis completed by HealthScience Concepts, Inc. Published June, 2003 Copyright 2003 Board of Regents, University of Minnesota. All rights reserved. This publication can be made available in alternative formats for people with disabilities. Direct requests to Sue Engelmann, Office of EVPP, 612-626-9186. -
Introduction The University of Minnesota (UM) and Minnesota State Colleges and Universities (MnSCU) commissioned a study of the status of health care resources in northwestern Minnesota and northeastern North Dakota; the study was to identify health care needs, the status of health care professionals, and the availability of health care education in the region. UM asked HealthScience Concepts, Inc., (HSCI) to review the resulting Northwest Minnesota Health Professions Study Report (hereafter referred to as the NWMN Study Report) and identify key findings and trends concerning health care employment and education in 19 counties in northwestern Minnesota and northeastern North Dakota (hereafter referred to as the study region). The UM also asked HSCI to suggest additional information, not in the NWMN Study Report, that would be helpful to the efforts of UM and MnSCU to address healthcare-related challenges in the study region. This analysis indicates that the large Northwest Minnesota Health Professions Study reveals current worker shortages in some health care work categories and suggests that the need for health care workers in many categories will increase as present workers retire and the population in the study region increases. Educational institutions in the study region offer diploma, certificate, and degree programs in nearly all health care work categories; it is clear that an infrastructure of facilities, laboratories, technology, academic and clinical faculty, and opportunities for clinical rotations and preceptorships is established. Data in the Northwest Minnesota Health Professions Study Report suggest that the programs and infrastructure may need bolstering in some categories so they meet the health care needs of the growing population. For a variety of reasons, this analysis does not yield a clear path from identifying specific shortages to discovering educational gaps to defining solutions to those gaps and, therefore, to shortages. However, this analysis does provide some important information that can form the foundation of problem-solving and planning by UM-TC and MnSCU. It also reveals some information gaps that these organizations may wish to fill. The data in the study report are comprehensive and diverse. Much of the information originates with research conducted by educational, state, county, and employer organizations; thus, dates and units of measurement vary from one data set to the next. In order to provide a measure of consistency over the course of this analysis, HSCI selected 5 health care work groups to track. We selected these work groups on the basis of their designations as Health Professional Shortage Areas (HPSA) and as having a lower provider-to-population ratio in the study area than in Minnesota statewide. Depending on information needs, UM-TC and MnSCU may wish to track other work groups in a similar manner. This analysis consists of the following sections: Summary of research methods and of the NWMN Study Report Current status of health care professions in the study region Projected status of health care professions in the study region Status of academic healthcare programs in the study region Conclusions and recommendations -4-
Data in this analysis are from the NWMN Study Report as the researchers prepared and presented it in February 2003. In some instances, information such as population projections may have been updated by state agencies since completion of the study; however the report and analysis cannot reflect such updated data. -5-
Research Methods Following an RFP process, the University of Minnesota (UM) and Minnesota State Colleges and Universities (MnSCU) commissioned the Northwest Minnesota Health Professions Study, retaining DMD Consulting (Grand Forks, North Dakota) and the Minnesota Center for Rural Health (Duluth, Minnesota) to conduct the study jointly. Data Sources The study focuses on 19 counties in northwestern Minnesota and northeastern North Dakota, presenting data about health care needs, employment in more than 40 professional healthcare and allied healthcare occupations, and health care professional education available in the study region. Researchers began their work in November, 2002, and presented the study report to UM and MnSCU in February, 2003. Researchers collected and compiled data from the following sources: University of Minnesota Office of Institutional Research & Reporting MnSCU System Research Office iseek healthcare channel Web sites and catalogues of post-secondary educational institutions Minnesota Department of Health State Offices of Rural Health, Minnesota and North Dakota Minnesota Hospital Association Minnesota Department of Economic Security Minnesota Department of Trade and Economic Development Minnesota Department of Children, Learning and Families National Institute of Health Policy Minnesota State Boards and Personnel Databases for various health professions North Dakota State Boards for various health professions North Dakota Department of Public Instruction Programs Offered and Programs Completed at North Dakota Institutions of Postsecondary Education Bureau of Health Professions Bureau of Labor Statistics ACT Department of Program Evaluation and Institutional Research Administrators survey of 48 students in the 5 healthcare programs at Northwest Technical College-East Grand Forks Survey of Altru Health Systems (Grand Forks, ND) and Riverview Healthcare Association (Crookston, MN) employees who expressed interest in pursuing additional education in a healthcare-related field Health Professional Workforce Feasibility Survey Researchers also conducted the Health Professional Workforce Feasibility Survey of health care employers in the study region. Designed to identify the demand for healthcare professionals and the support for health professions education in the counties within the study region, the survey sample included 362 organizations in North Dakota and 388 organizations in Minnesota. -6-
Researchers received 186 responses, for a response rate of 25%. Table 1 presents the categories within each sample. Table 1: Organizations in the Health Profession Workforce Feasibility Survey Type of Healthcare Minnesota North Dakota Organization Clinic and medical center 57 44 Hospital and medical center 4 6 VA Center 0 1 Home care organization 4 13 Assisted living facility 24 10 Health care center 17 12 Dentist 48 69 Chiropractor 44 44 Nursing home 31 20 Healthcare and medical 9 0 healthcare center Home health service 0 3 Mental health center 8 16 Pharmacy 49 47 Optical center 36 49 Rehabilitation and therapy center 23 7 Nursing service 9 0 Health department 2 2 Miscellaneous health care providers or facilities including assisted living 65 29 The facilities reported only for their sites within the 19 counties forming the study region. The survey yielded the following categories of data: currently employed health professionals number of current vacancies number of health professionals being recruited number of vacancies by facility type health professions vacancy rate vacancies due to new professions rate vacancies due to employees leaving rate FTEs to be recruited in each work category during coming 3 years Focus Group and Interviews Researchers conducted a focus group with the Board of Directors of the North Region Health Alliance, a cooperative of medical organizations in 18 communities in northwest Minnesota and Grand Forks, North Dakota. They also conducted individual interviews with healthcare employers and economic developers. Questions used for the focus groups and the interviews focused on assessing opinions about the shortage of healthcare workers, impressions of capacity, and need to expand health professions education. -7-
Limitations The researchers cited several limitations of both primary and secondary data gathered for this study. Limitations of the primary data: Short response times for participants to complete and return forms and surveys may have resulted in low response rates. The long survey (Health Professional Workforce Feasibility Survey) included 48 work categories and was directed to 14 types of facilities; that length and complexity could have affected the response rate. Space limitations on the survey precluded defining clinical rotation and preceptorship ; several people called researchers seeking definitions of those terms. Limitations of secondary data: Researchers gathered information from various institutional and system sources; data were in different formats and contained different data elements. Data derived from several institutional databases were described using differing terminology. The study required inclusion of information from 19 counties in 2 different states; it is challenging to gather such information in ways that can be reported regionally. -8-
Current Status of Health Care Professions in the Study Region Several sets of data in the NWMN Study Report suggest that, in many counties in the northwest region, fewer health care professionals in various specialties are employed than would be considered optimal. Those data sets are: Health Professional Shortage Area (HPSA) designations; provider to population ratios; vacancy rates; current vacancies and current recruiting; and focus groups. HPSA Designations (pages 43-53, NWMN Study Report) Health Professional Shortage Area (HPSA) designations are based on the number of practitioners available for a defined number of people and within a specified travel time, as well as on income levels of populations in counties. Table 2 below summarizes the HPSA Designations in 4 categories in the 19 counties of interest in this study. Table 2: HPSA Designations Category Criteria Number of Counties (n=19) Primary Care Physicians <1 primary care physician/3,500 15 people lack of access to physician care within 30 minutes travel time Mental Health <1 psychiatrist/30,000 people travel time: not defined in report 19 Dental Not defined in report whole counties: 13 partial areas: 2 other: 1 not designated: 3 Critical Nursing Not defined in report whole counties: 12 not designated: 7 These data reflect 2002 and 2003 reports. Provider to Population Ratios (page 42, NWMN Study Report In 5 key health care work categories, the ratio of provider to population is lower in the study area (northwestern Minnesota plus northeastern North Dakota) than in Minnesota statewide. The greatest ratio differences are for dentists and registered nurses. Information is not provided to define a shortage as a given ratio of provider to population. Instead, the importance of the data is that ratios are lower in the study area compared to Minnesota statewide. (Note: the Study Report characterizes the study area ratios as higher ; that appears to be an erroneous interpretation of ratio differences.) -9-
Category Table 3: Provider to Population Ratios Minnesota statewide: #/100,000 population (state population=4,919,479) Study area: #/100,000 population (area population=464,560) Primary Care Physicians 100 97.2 Specialty Physicians 129.63 127.1 Dentists 57.6 38.9 Registered Nurses 904 728.8 Pharmacists 99.5 103.6 These data reflect reports dated 2000 and 2002. In several sections of this analysis, HSCI presents additional data concerning these work categories; doing so provides a way to track and interpret some of the large quantity of diverse data in the study report. Vacancy Rates (pp. 65-67, NWMN Study Report) The Health Professional Workforce Feasibility Survey conducted for the NWMN Study yielded the following information about vacancy rates in the study region in 48 health care work categories: the overall vacancy rate is 6.5%; the vacancy rate exceeds 6% in 24 of the health care work categories; the vacancy rate is 0.0% in 7 health care work categories. Economists define a shortage as a sustained vacancy rate above 6%; the report does not define sustained. Based on that definition, an overall shortage of health care workers may exist in the study region. More specifically, a shortage may exist in 24 health care work categories; the other 24 health care work categories have a vacancy rate below 6% and, therefore, are not classified as having a shortage. The vacancies are associated with newly created positions plus employee departures. The Study Report does not indicate the length of time positions have been vacant; thus we do not know whether the vacancies meet the economists criteria for a shortage (sustained vacancy rate above 6%). Table 4 presents the work categories with vacancy rates exceeding 6%. -10-
Table 4: Work Categories with Vacancy Rates Exceeding 6% Vacancy Rates: 8.1% to 20.0% Vacancy Rates: 6.2% to 7.6% Cardiovascular technologists (20.0) RN, Associates Degree (7.6) Other specialty care physicians (15.6) Pharmacists (7.5) Psychiatric techs (15.6) Dentists (7.4) Medical assistants (15.2) Phlebotomists (Blood lab tech) (7.4) Emergency medical technicians (12.5) Dental hygienists (7.3) Physician assistants (12.3) Practical nurses (6.9) Recreational therapists (11.8) Optometrists (6.6) Pharmacy tech, not certified (9.7) Mental health counselors (6.6) Medical lab tech, Associate Degree (9.1) Health care administrators (6.3) RN, Bachelors Degree (8.4) Physical therapists (6.2) CRNAs, NPs, CNSs, CNMs (8.3) Primary care physicians (8.1) Cytotechnologists (8.1) Dieticians (8.1) The 5 categories we track in this analysis primary care physicians, specialty physicians, dentists, RNs, and pharmacists all appear in Table 4, identified as having shortages. The survey on which these vacancy rates are calculated was sent to 757 health care organizations in the study region; 186 surveys (25%) were returned. Current Vacancies and Current Recruiting (pp. 58-64, NWMN Study Report) The Health Professional Workforce Feasibility Survey conducted for the NWMN Study yielded the following information about employment in the study region: number of full-time-equivalent (FTE) employees; number of FTE vacancies (Sally Buck explains this category: number of FTE positions unfilled but for which the organization is not actively recruiting, e.g., reason unknown, or the vacancy currently exists but the organization has signed a contract with someone, such as a physician, who will begin employment at a defined future time); and number of FTE positions for which the organization is actively recruiting (Sally Buck explains: these may be positions currently open and/or anticipated to be open in the future). Table 5 presents that information for the 5 health care professions we track in this analysis. -11-
Table 5: Five Health Care Work Groups Current Employment, Current Vacancies, Currently Being Recruited Work Category # Currently Employed # Current Vacancies # Currently Recruiting Primary care physicians 260 23 15 Specialty physicians 301 55 20 Dentists 67 5 9 RNs (Associates & Bachelors degrees) 1288 111 38 Pharmacists 143 12 10 Thus, the number of FTE vacancies emerging from this survey provides little information to use in characterizing the current status of health care professions in the region. However, information about positions for which health care organizations are actively recruiting suggests the potential for regional employment in health care professions (keeping in mind that only 25% of organizations returned the survey). From these data we do not know how long organizations have been recruiting, the degree of difficulty they anticipate in filling positions, or the date(s) by which they hope to fill positions. We can assume that qualified health care professionals in nearly every subcategory could expect to apply for open positions in the study region. The examination of vacancies by facility type shows that health systems report the highest numbers of vacancies. Within health systems, vacancies are greatest in the category of nursing, primary care and specialty care physicians, and technologists. However, as indicated above, organizations may list the vacancies but not be actively recruiting to fill them. Thus, these data do not necessarily indicate the number of positions actually available to job candidates. Table 6 presents vacancy data for the 5 health care work groups we track in this analysis. -12-
Table 6: Vacancy Data for 5 Health Care Work Groups Hospital Health System Center Clinic Health Dept. Nursing Home Hospital/Clinic Care Medical Service Therapy Center Dental Clinic Pharmacy Optical Center Center Center Other Primary 1 19 0 4 0 1 0 1 1 0 0 0 0 0 0 0 care physicians Specialty 0 53.5 1 1 0 0 0 0 0 0 0 0 0 0 0 0 physicians Dentists 0 0 0 1 0 0 1 1 0 0 5 0 0 0 0 0 RNs 2 97.5 0 2 0 8.9 0 6 2 4 0 2 0 0 2 4 Pharmacists 0 4.4 1 0 0 0 0 0 0 0 0 4.8 0 0 0 0-13-
Focus Groups (pp. 271-273; 353-355, NWMN Study Report) During the focus groups, participants mentioned concerns about shortages in various work categories. The following list tabulates the categories and the number of times someone mentioned each category as having a shortage: nursing: 2 nursing assistants: 2 physicians: 1 licensed personnel: 1 pharmacists: 1 techs: 1 pharmacy techs: 1 X-ray techs: 1 lab techs: 1 radiology technicians: 1 coders: 1 When asked why health care workers may leave the study region to work elsewhere, participants mentioned the following reasons: salary and benefits (mentioned by 6 people) practice situations, e.g., call, work hours (mentioned by 3 people) spouse wanting a different location for career opportunities (mentioned by 3 people) single professionals seeking larger communities for social life (mentioned by 1 person) cost of housing and lack of rental properties (mentioned by 1 person) Summary: Current Status of Health Care Professions The data presented in the NWMN Study Report yield the following information about the current status of health professions in the study region: With the exception of a few counties, the study region meets the criteria for designation as a Health Profession Shortage Area for the categories of Primary Care Physician, Mental Health, Dental, and Critical Nursing. The ratio of provider to population is lower in the study region than it is in Minnesota statewide in 5 categories: Primary Care Physician, Specialty Physician, Dentist, Registered Nurse, and Pharmacist. In 24 of 48 health care work categories, the vacancy rate exceeds 6% (survey response was 25%). If that is a sustained rate, it meets economists description of a shortage. Organizations that responded to the survey are recruiting for nearly every work category. The categories with highest recruiting are nursing, physicians and medical support, and dental. In focus groups, participants mention shortages as key issues in health care, and they emphasize the role of salary and benefits, practice situations, careers for spouses, social life, and housing costs as factors in health care workers decisions to leave the region. None of the data sets reveal an oversupply of health care workers in any work category. Most of these data seem to indicate relative shortages rather than shortages based on defined baseline criteria. For example, when a facility reports a shortage or vacancy or recruiting activity, on what basis is it making that designation? Are there data indicating that an -14-
organization with a given number of beds or defined patient population size should have specific numbers of FTEs in each of several work categories? If so, what are those data and how are they derived? Are the facilities calculating their vacancies based on such data, are they using morearbitrary numbers, or are they using such subjective data as comments from employees who feel overworked, or from exit interviews, or from other sources? Baseline designations would help interpret the strength of the numbers in these data sets. Such designations also would help project future needs for health care professionals based on population projections. -15-
Projected Status of Health Care Professions in the Northwest Region Several sets of data suggest that the need for health care professionals is likely to increase in the study region. The key data sets are: regional population projections; age distributions of current health care professionals in the region; retention issues; estimated employment, 1998 and 2008; and projected recruitment, 2003 2006. Regional Population Projections (pp. 81-82, NWMN Study Report) According to the 2000 census, the population in the study region was 464,560. Projections are that the population will increase to 492,370 in 2010, and to 519,276 in 2020. The increase from 2000 to 2020 is 54,716 people, or 11.8%. Those additional people will need health care. A higher proportion of that population will be older than 65 because the number of people age 65 to 84 is projected to have the greatest rate of increase. According to the National Center for Health Statistics, people older than age 65 have twice as many physician visits annually as people younger than age 45. These projections suggest: a future high need for long-term care services; and increased demand for physician and primary care ambulatory care providers. However, the NWMN Study Report appears to provide no basis for defining the actual need. As suggested earlier, it would be helpful to know recommended ratios of health care provider to 100,000 population in key work categories. We could then calculate the numbers of providers needed to meet the health care needs of the increased total population in the study region as well as of important population subgroups. Age Distributions of Current Health Care Workers in the Region (pp. 83-99, NWMN Study Report) In the study region, more than 30% of professionals are older than age 50 in the following health care work categories: clinical nurse specialists, dentists, pharmacists, registered nurses, respiratory therapists, long-term care administrators, and specialty care physicians. Thus, as the study region population increases and ages: the workforce in important health care areas will age; and more than 30% of the current health care workforce will retire. The study data of age groups by workforce category come from a range of sources, the various sources use different age categories, and data are not reported for all work categories in the entire study region. Thus, it is impossible to aggregate the data in order to compare age distributions across all work categories. However, to understand the implication of the age group data it may be useful to focus on age groups for the 5 categories for which we have provider-to-population ratio data (recall that the ratio in the study region for each of these groups is lower than it is in Minnesota statewide). -16-
Table 7 presents information about the age characteristics of those groups; because the data come from state sources, they are not available by county; instead, they are reported as northwest Minnesota (NW MN) and northeast North Dakota (NE ND). Table 7: Age Characteristics of 5 Health Care Work Groups Work Group Location Age Number (Percent) Primary care NW MN 41 or older 73 (73%) physicians NE ND 46 or older 189 (53%) Specialty care NW MN 41 or older 30 (94%) physicians NE ND 41 or older 465 (83%) Dentists NW MN 40 or older 59 (75%) NE ND (not reported) -- -- Registered nurses NW MN 41 or older 753 (74%) NE ND 45 or older 1221 (49%) Pharmacists NW MN 41 or older 123 (68%) NE ND (not reported) -- -- Despite the variability of data groupings, it is clear that a large number of current health care professionals in these groups are likely to be retired by 2020 when the population in the study region reaches the projected 11.8% increase; similar trends exist in other work categories. Based on these data, merely replacing those who retire is unlikely to meet the health care needs of the study region. In addition, health care workers are likely to leave their jobs for other reasons, thus increasing the number of new workers needed over the coming years. Retention (pp. 105-109, NWMN Study Report) The discussion of retention summarizes national studies and studies of selected groups of rural health care workers; the emphases seem to be on opinions and job satisfaction rather than specifically on health care workers intentions to remain in, or leave, their jobs. The implication is that health care workers in many groups are dissatisfied, and dissatisfaction may contribute to health care worker turnover rates that average 20%, exceeding average turnover rates of 13% to 18% in all industries. In 2000, turnover rates among nursing staff in Minnesota nursing facilities were: RNs, 33%; LPNs, 31%; and NAs, 62%. The study presents very little information about retention of health care workers in states, rural areas, or the specific study region, so it is not possible to predict retention rates over time or to factor retention rates into attempts to predict future needs for health care workers in the study region. However, it is possible to conclude that health care worker turnover is high and that job dissatisfaction is an important factor perhaps more in rural areas than in metropolitan areas. -17-
Estimated Employment: 1998 and 2008 (pp. 100-104, NWMN Study Report) The NWMN Study Report includes employment data for 1998, estimated employment for 2008, and both percent and numeric change for that 10-year interval. However, the data are for all of Minnesota and all of North Dakota; such data for the study region would be useful. To provide a sense of the trend in employment, Table 8 presents these statewide employment data for the 5 health care work groups with low provider-to-population ratios in the study region. It is not known whether we can assume proportional changes for the study region. Table 8: Statewide Job Outlook for 5 Health Care Work Groups Work Group (Location) 1998 Employment 2008 Employment Percent Change Numeric Change Primary care MN 12,900 16,350 27% 3,450 physicians ND 950 1,000 3% 50 Specialty care MN 12,900 16,350 27% 3,450 physicians ND 950 1,000 3% 50 Dentists MN 3,200 3,500 8% 300 ND 250 250 0% 0 Registered MN 39,800 46,850 18% 7,050 nurses ND 6,750 7,900 17% 1,150 Pharmacists MN 3,450 3,850 11% 400 ND 600 600 0% 0 With the exception of the dentist and pharmacist work groups in North Dakota, these data project employment increases for each of the 5 health care work groups. The data do not indicate whether the employment numbers reflect FTEs or people actually employed. Projected Recruitment, Upcoming 3 Years (pp. 77-79, NWMN Study Report) Results from the Health Professional Workforce Feasibility Survey indicate that the 25% of organizations that returned surveys expect to recruit in all except 2 health care work categories: medical records technologists and certified medical lab techs. The highest number for planned recruiting is 492.8 for all types of nurses. Table 9 focuses on the 5 health care work groups we track in this analysis (those with low provider-to-population ratios in the study region), presenting data about current vacancies and the number of workers the survey respondents plan to recruit during the coming 3 years. -18-
Table 9: Projected Recruitment for 5 Health Care Work Groups in the Study Region Work Category # Current Vacancies # Plan to Recruit During Next 3 Years Primary care physicians 23 16 Specialty care physicians 55 21 Dentists 5 13.3 Registered nurses (Associates 111 102.9 and Bachelors degrees) Pharmacists 12 26.5 These numbers are consistent with other information in the study indicating that vacancies exist and that organizations expect to recruit in these 5 work groups as well as in the other 43 health care work groups that are the focus of the study. Summary: Projected Status of Health Care Professions The data presented in the NWMN Study Report yield the following information about the projected status of health professions in the study region: By 2010, the population in the region is expected to increase from 464,560 (2000 census) to 492,370; by 2020, the population is projected to be 519,276. That represents a 20-year increase of 54,716 people, 11.8%. The number of people age 65 to 84 is projected to have the greatest increase during that interval, suggesting increased need for long-term care services, physicians, and primary care ambulatory care providers. More than 30% of the current health care work force is older than 50; these people are likely to have retired by 2020. Nationally, turnover rates for health care workers are higher than for other industries; turnover rates among nursing staff in Minnesota greatly exceed health care worker turnover rates in the US. Statewide, healthcare employment data predict increases as high as 27% between 1998 and 2008. In the study region, during the next 3 years organizations expect to recruit in nearly all categories, with the highest planned recruiting for registered nurses, both Associates and Bachelors degrees. The trends clearly indicate population increases and high rates of retirement among health care workers, and they suggest increased recruitment and challenges retaining health care workers. The information provided does not appear to address shortages or any difficulty filling positions. A better understanding of the projected status of health care professions would be possible with statistics about the desired ratio of health care workers to population; with that information, we could calculate the numbers needed in the region in each work category. We could then consider projected retirement, projected numbers leaving their jobs, and projected newly certified and licensed health care workers and calculate projected shortages or surpluses. -19-
Status of Academic Healthcare Programs in the Study Region The NWMN Study Report provides a great deal of descriptive data regarding educational programs available in the study region. From these data we can: characterize the types of programs and numbers of graduates in 2001; suggest, to a certain extent, the current and future capacity of programs; understand that financial assistance is available in various forms to those who want to pursue studies in a health care program; and note that some high school students in the region who express an interest in entering a health care education program also express an interest in attending college in the study region. Existence of Programs (pp. 125-133; 255-262, NWMN Study Report) According to the MnSCU Program Inventory and institutional Web sites and catalogues, certificates, diplomas, and degrees are available in 52 health care program areas in the study region. The number of programs available at all institutions in the region totals 94; in the coming 2 years MnSCU is suspending 14 of those programs. Of 51 health care work categories, education currently is unavailable in the region for 10 categories; with the planned suspension of programs by MnSCU, education in the region will be unavailable for 3 additional categories. Table 10 identifies the regional educational resources available for the 5 health care professions work groups with low provider-to-population ratios in the study region. Table 10: Regional Educational Programs Available for Selected Health Care Work Groups Work Category Regional Educational Programs (2001 graduates) Primary care physicians University of North Dakota (53 graduates in medicine ) Specialty care physicians Work category not listed Dentists No program available in region Registered nurses (Associates and Bachelors Northland CTC (47 Associates degree degrees) graduates) Bemidji State University (18 Bachelors degrees graduates)* Concordia College (data not listed) Minnesota State University-Moorhead (25 Bachelors degrees graduates)* North Dakota State University (134 graduates: NDSU plus UND) University of North Dakota (see NDSU) Pharmacists North Dakota State University (54 graduates) * Graduates from Bemidji State University and Minnesota State University-Moorhead are RNs completing their bachelor s degrees. They are not new to the workforce. -20-
Tables in the Study Report show 100% rates of employment for those graduating from nursing programs; employment data for the other 4 work categories are not provided. The employment data do not indicate whether the graduates accept work in the study region, go elsewhere in Minnesota or North Dakota, or move to other states. The Study Report presents information about numbers of applications, admissions, matriculations, transfers, and students enrolled in majors for various health care programs in various regional institutions. However, those data do not necessarily predict numbers of graduates; they also cannot correlate with information provided about program capacity. Thus we do not include this information in this analysis. Table 11 presents information about work vacancies, the existence of regional education programs, and the number of graduates for each of the 5 health care professions with low provider-to-population ratios in the study region. Table 11: Vacancies and Regional Graduates in Selected Health Care Work Groups Work Category # Current Vacancies (2003) Health Professions Program in Region Total HP Graduates (2001) Primary care physicians 23 Yes N/A Specialty care 55 No N/A physicians Dentists 5 No 0 Registered nurses* 111 Yes 293 (Associates and Bachelors degrees) Pharmacists 12 Yes 54 * Graduates from Bemidji State University and Minnesota State University-Moorhead are RNs completing their bachelor s degrees. They are not new to the workforce. In Table 11 the vacancies are for 2003 and the graduation data are for 2001; thus we cannot assume that the number of registered nurse and pharmacy graduates is sufficient to fill the vacancies. However, this issue probably merits additional research to determine: where the 2001 graduates accepted employment both in the region and in other areas; how many vacancies existed at the time of 2001 graduation; and how many vacancies remained after the 2001 graduates accepted employment and were no longer job candidates. Similar data for several additional years would also be valuable and would help establish any relationships between numbers of graduates and numbers of vacancies. Those relationships might enable conclusions about whether the education programs are adequate to meet the needs of employers. Current and Projected Capacity of Programs (pp. 134-136; 144-148, NWMN Study Report) Although information in several areas indirectly addresses program capacity, the data about current and projected clinical rotations and preceptorships probably are the most useful in understanding capacity. -21-
Space. The Study Report presents data about projected surpluses and deficits of space in classrooms, teaching laboratories, and open laboratories at regional MnSCU institutions; several institutions project space deficits in both teaching and open laboratories, and NTC-Moorhead also projects a space deficit in classrooms. These projections do not reflect space utilization by discipline, and they also are not presented in conjunction with enrollment numbers. Thus, we cannot determine such facts as projected capacity for health care programs individually or collectively, or how many students would have to be turned away from a program because of laboratory space deficits of a certain square footage. Faculty. Deans from selected programs provided comments about any difficulties in recruiting or retaining faculty. However, the programs whose deans provided that information are not identified. It may be useful to know current numbers of health care program faculty, projected needs for faculty, and numbers of faculty needed to support current and projected numbers of students in each program. Distance Delivery. Many health care courses in the region are delivered at a distance: Internet: 35 Interactive TV: 67 It would be useful to know how many students are served by these distance courses, how many additional students could participate, or how many additional courses could be offered via distance technologies. Rotations and Preceptorships. Data about current and projected clinical rotations and preceptorships available at health care employers in the region may provide the most-useful indication of the current and near-future capacity of programs. These data could be suspect, as the researchers received numerous calls questioning the definitions of the terms. However, the numbers are concrete so they might be very useful. Table 12 focuses on the 5 work categories with low provider-to-population ratios, presenting current and projected clinical rotations and preceptorships. Table 12: Current and Projected Clinical Rotations and Preceptorships in Selected Work Categories Work Category # Clinical Rotations/Year (2003) # Preceptorships/Year (2003) Clinical Rotation Slots Offered over Next 3 Years Preceptorships Offered over Next 3 Years Physicians 32 3 31 2 Specialty care 9 1 9 1 physicians Dentists 4 2 8 2 Registered 252 77 311 87 nurses Pharmacists 80 15 78 10-22-
The wording for the projections is unclear; employers might be offering these slots each of the next 3 years (i.e., 93 total clinical rotation slots for physicians), or they might be offering only these slots as a total (i.e., approximately 10 slots for physicians each year). If the slots will be available each of the next 3 years, these data may indicate that the capacity of nursing and dentistry programs will increase, physicians and pharmacy programs will decrease, and specialty care physicians will remain static. Those projections could indicate that the numbers of graduates in these work categories in the study region will decrease over the next 3 years. It may be useful to know what influences the changes in numbers of slots offered. Financial Assistance (pp. 149-165; 211-220 NWMN Study Report) Financial assistance is available in various forms. The Study Report presents information about the assistance in various forms, so it is not possible to aggregate the information to gain a complete picture of financial assistance. The report presents data about the following forms: tuition forgiveness offered by healthcare employers; employer funding for expanding educational programs; in-kind educational support for employees; institutional/program support for students; support from regional foundations; and state loan and scholarship programs. The availability of financial assistance is important to enrollment in programs and, therefore, to the numbers of graduates from healthcare programs. Altru Health systems (Grand Forks, ND) and Riverview Healthcare Association (Crookston, MN) asked employees interested in additional healthcare-related education to complete a survey. One-third of the 114 respondents indicated loss of income would be a barrier to obtaining additional education, and nearly onethird indicated that the cost of tuition would be a barrier. It may be useful to know whether the available financial assistance meets the needs of these employees as well as the needs of others who want to enroll in health care educational programs at institutions in the study region. High Schools: Enrollment & Education/Career Plans (pp. 221; 166-189; NWMN Study Report) In the Minnesota counties in the study region, 12 th grade enrollment is projected to increase from the current 2003 enrollment of 3,643 to 3,651 (2004) and 3,750 (2005). In contrast, 12 th grade enrollment in the involved North Dakota counties is projected to decrease from the current 2003 enrollment of 2,660 to 2,590 (2004) and 2,458 (2005). The total 12 th grade enrollment in the study region is projected to decrease from the current 6,303 to 6,241 in 2003 and 6,208 in 2005. That decline in enrollment could suggest that fewer students would enroll in higher education institutions in the study region, and that health care programs would attract fewer students, as well. According to the ACT Student Profile, 616 2002 high school graduates in the study region expressed an interest in healthcare-related programs in higher education. Of those students, 144 listed an institution in the study region as their first choice for college. It would be useful to know the strength of the students intention to attend one of those institutions, as well as how many of those students actually began their studies at a post-secondary school in the study region. Data about the number of new undergraduates (freshmen plus new transfer students) in -23-
institutions in the study area are only available for 2001, so it is not yet possible to compare the ACT data about choices with data about new students enrolling in fall, 2002. -24-
Summary: Status of Academic Healthcare Programs in the Study Region The data presented in the NWMN Study Report yield the following information about healthcare education programs in the study region: Of 51 health care work categories, education programs for only 10 are not available in the study region. Two of the programs for which regional education is not available are specialty care physicians and dentists; those are 2 of the categories with HPSA designations and low provider-to-population ratios. Graduates of health care programs in the region have nearly 100% employment; however, vacancies persist. The Study Report does not indicate where program graduates are working. Data concerning current and projected clinical rotation slots and preceptorships suggest that the capacity of education programs may decline slightly. The existence of programs at institutions throughout the region, technology for distance courses, faculty, clinical sites, and prospective students indicates that the infrastructure is available for continuing to prepare health care workers. Financial assistance in various forms is available to people who wish to enter health care programs. High school students in the study region who are interested in health care programs also express interest in programs at institutions in the region. Once again, data are for varying years and are provided in different formats, suggesting that we cannot draw many conclusions concerning healthcare programs. It may be useful to identify some key questions and query the database prepared as part of this health professions study. Such computer analysis may sort through the great amount and diversity of data to provide additional useful information. -25-
Conclusions and Recommendations The Northwest Minnesota Health Professions Study Report provides an incredible wealth of descriptive data concerning health care in the study region (northwestern Minnesota, northeastern North Dakota) as well as in Minnesota and the United States and concerning health care employment and educational programs in the study region. Interpreting these data in a manner that addresses concerns about shortages and solutions to these shortages proves to be a formidable challenge. For a variety of reasons, this analysis does not yield a clear path from identifying specific shortages to discovering educational gaps to defining solutions to those gaps and, therefore, to shortages. However, this analysis does provide some important information that can form the foundation of problem-solving and planning by UM-TC and MnSCU. First: shortages of health care workers in the study region do exist; the extent of the shortage varies by work category. The overall vacancy rate in healthcare professions is 6.5%; in many work categories the vacancy rate is much higher. Health care organizations currently are recruiting in the 5 work categories we track in this analysis, as well as in many other categories. We might have a better understanding of the severity of the shortages if we had precise recommendations for the appropriate number of professionals in each work category needed for each 1,000 (or other defined number) people in a region. We could then compare the actual workforce with recommendations and measure the nature of the shortage in each work category. In addition, we could quickly calculate the needs in 2010 and 2020, by health care work category, given the projected increases in population in the study region. However, such ratio analysis would be only one part of the puzzle; studies that rely on ratios also consider poverty rates and access to health insurance as dimensions important to understanding the ratios. Second: the population in the study region is expected to increase, the greatest increase will be of people age 65 to 84 (who need more health care than do people in other age groups), and many current health care workers will be retiring as the population increases and health care needs increase. The retirements plus increased needs for health care suggest that health care worker shortages will worsen; any goal of merely replacing those who retire represents an inadequate solution. Third: educational institutions in the study region provide diploma, certificate, and degree programs that address nearly all of the health care work categories of interest in this study. The infrastructure is in place for key health care educational programs. Institutions offering these programs have classroom and laboratory space, technology for distance delivery, academic and clinical faculty, and workplaces to offer clinical rotations and preceptorships. These programs are supplying graduates in nearly all health care work categories. As noted in Table 10, of the 5 work categories with low provider-to-population ratios, only dentistry is not represented in regional institutions. Nonetheless, vacancies persist and we anticipate more vacancies in various healthcare work groups. The data presented in the Northwest Minnesota Health Profession Study Report document shortages of health care workers. But they also document well-established educational programs in nearly all work groups, solid numbers of graduates, and employees who are interested in completing additional education and remaining in the health care field. -26-
Given the existing resources, creating new health care educational programs does not seem to be necessary. In this time of restricted budgets, UM and MnSCU may wish to consider several strategies for meeting the current and future healthcare needs of the study region. These organizations might: identify ways to maximize the educational efficiency of existing programs in the study region, thereby increasing the number of graduates, especially in healthcare work categories with shortages and vacancies; examine factors that could influence greater numbers of healthcare workers to seek employment, and remain, in the study area; consider ways to define health care career pathways that individuals could follow by building on experience and obtaining additional education in increments enabling them to progress while also remaining in the region; explore educational partnership structures that would yield a degree program in the region for dentists. -27-