Health Care Workforce: HRSA Action Needed to Publish Timely National Supply and Demand Projections
Published: 2013-09-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: For over a decade, government, academic, and health professional organizations have projected national shortages of health care professionals, which could adversely affect patients' access to care. However, there is little consensus about the nature and extent of future shortages, partly because of the complexity of creating projections and uncertainty about future health care system changes. Up-to-date workforce estimates are essential given the significant federal investment in health care training programs. Within HHS, HRSA is responsible for monitoring health care workforce adequacy; to do this, HRSA conducts and contracts for workforce studies.
GAO was asked to provide information about health care workforce projections. This report examines the actions HRSA has taken to project the future supply of and demand for physicians, physician assistants, and advanced practice registered nurses since publishing its 2008 report. GAO reviewed HRSA's contract documentation, select delivered products, and timeline goals for publication. GAO also interviewed HRSA officials, workforce researchers, and provider organizations.
section_title: What GAO Found
paragraphs: Since 2008, the Health Resources and Services Administration (HRSA) within the Department of Health and Human Services (HHS) has awarded five contracts to research organizations to update national workforce projections, but HRSA has failed to publish any new reports containing projections. As a result, the most recent projections from HRSA available to Congress and others to inform health care workforce policy decisions are from the agency's 2008 report, which is based on data that are more than a decade old. While HRSA created a timeline for publishing new workforce projection reports in 2012, the agency missed its goal to publish a clinician specialty report by December 2012 projecting the supply of and demand for health care professionals through 2025. HRSA officials attributed the delay in publishing this report to data challenges and modeling limitations. HRSA has also revised its timeline to postpone publication of two other health care workforce reports, as shown in the table below. HRSA officials said that the agency does not have standard written procedures for preparing a report for publication after final reports are delivered from contractors, which may impede its ability to accurately predict how long products will take to review and monitor their progress through the review process.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Administrator of HRSA expedite the review and publication of HRSAs report on national projections for the primary care workforce, create standard written procedures for report review, and develop tools to monitor report review to ensure timeline goals for publication are met. HHS agreed with GAOs recommendations and provided technical comments.

section_title: Letter
paragraphs: For over a decade, several government, academic, and health  professional organizations have projected national shortages of health  care professionals, which could result in delays in getting care, or  patients not receiving needed care. However, there is little consensus  about the nature and extent of any future shortages. In 2008, the Health  Resources and Services Administration (HRSA)—the agency within the  Department of Health and Human Services (HHS) responsible for  monitoring the supply of and demand for health care professionals— published a physician workforce report that projected a shortfall of  approximately 49,000 full-time equivalent (FTE) physicians by 2020.
That same year, the Association of American Medical Colleges (AAMC)  projected a gap of 124,000 FTE physicians by 2025. In contrast, one  recently published study found that increases in physician productivity  due to greater use of technology and incorporation of nonphysician  providers into team-based care delivery models could offset projected  shortages of primary care physicians. Differences among projections  may arise partly because accurately determining the supply of and  demand for health care professionals is a difficult task due to gaps in  available supply data, especially for nonphysician providers, and a  number of uncertainties that affect future demand, such as technological  advances in medicine and changes in disease prevalence. HRSA and  others attempting to develop new projections must also account for a  changing health care landscape, due in part to the implementation of the  Patient Protection and Affordable Care Act (PPACA), as amended by the  Health Care and Education Reconciliation Act of 2010. The  Congressional Budget Office has estimated that PPACA will extend  health insurance coverage to 25 million uninsured individuals beginning in  2014. PPACA also contains provisions that have the potential to change  the way health care is delivered, as well as the size and composition of  the health care workforce. To ensure an adequate health care workforce  for the nation, the federal government makes a significant investment in  training programs. For example, total federal spending for workforce  training was about $14 billion in fiscal year 2012. Up-to-date workforce  estimates are essential information for Congress as it considers policy  options to address health care workforce issues, including targeted  funding for training programs.
HRSA is the primary federal agency responsible for ensuring and  increasing access to health care services, particularly for medically  underserved populations, and for enhancing the capacity of the health  care workforce. Within HRSA, the Bureau of Health Professions (BHPr)  has multiple responsibilities related to workforce development, including  conducting and contracting for studies on the supply of and demand for  health care professionals. In 2006, we found that HRSA had published  few national workforce projections despite the importance of such  assessments to setting health care workforce policy, and we  recommended that HRSA develop a strategy and establish timeframes to  more regularly update and publish national workforce projections for the  health professions. In 2012, HRSA created a timeline, establishing goals  for producing national projections and a schedule for periodic updates.
Given the wide range of estimates that have been generated about how  many health care professionals may be needed, you asked us to provide  information about health care workforce supply and demand projections.  This report examines the actions HRSA has taken to project the future  supply of and demand for physicians, physician assistants, and advanced  practice registered nurses (APRN) since publishing its 2008 physician  workforce report.
To examine actions HRSA has taken to project the future supply of and  demand for health care professionals, we reviewed relevant sections of  HRSA’s contracts with research organizations that produce workforce  models and projections, including statements of work and timelines for  deliverables. To obtain more detailed information about delivered  products, we reviewed a published report and a data and methodology  guide provided by a contractor to HRSA. We also reviewed a workforce  projection model created under contract and used it to examine projected  differences between the supply of and demand for physicians by specialty  in 2025 with and without the addition of nonphysician providers. To  enhance our understanding of the model’s capabilities and structure,  HRSA officials provided us with a demonstration and tutorial on the use of  this model to create workforce projections. Although our reporting  objective encompassed workforce reports as evidence of actions taken,  we did not review reports produced by contractors that HRSA had not  approved, finalized, and published for public use because it was beyond  the scope of our review to assess the quality or completeness of such  interim products. We also reviewed a document summarizing workforce  data collection and analysis activities conducted by BHPr. We interviewed  officials from BHPr to clarify and confirm information about the status of  HRSA’s workforce projections and to obtain information about key  updates and changes to its models since its 2008 physician workforce  report, as well as challenges they face in updating projections. We also  asked officials about policies and procedures for reviewing and publishing  projection reports to assess the extent to which HRSA monitors its  progress toward meeting timeline goals. We assessed these policies and  procedures using criteria from Standards for Internal Control in the  Federal Government. We also compared dates contained in the timeline  HRSA created in 2012 for publishing updated national health care  workforce projections with contractual dates for product deliveries, as well  as with status updates provided by BHPr officials to evaluate HRSA’s  progress. We also interviewed health care workforce researchers and  representatives from health care professional associations to gain  additional perspectives on the challenges of creating workforce  projections.
We conducted this performance audit from May 2013 through September  2013 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: An adequate supply of health care professionals is necessary to ensure  access to needed health care services. HRSA estimated that there were  approximately 780,000 physicians and 261,000 physician assistants and  advanced practice registered nurses engaged in patient care in 2010.  Part of maintaining an adequate health care workforce involves projecting  the future supply of health care professionals and comparing that supply  to the expected demand for health care services to determine whether  there will be enough providers to meet the demand. Such projections can  provide advance warning of shortages or surpluses so that health care  workforce policies, such as funding for health care training programs, can  be adjusted accordingly. In its 2008 physician workforce report, HRSA  noted that due to the long time needed to train physicians and to make  changes to the medical education infrastructure, policymakers and others  need to have information on the adequacy of the physician workforce at  least 10 years in advance. We have also previously reported that  producing supply and demand projections on a regular basis is important  so that estimates can be updated as circumstances change.
Health care workforce projections typically measure the supply of health  care professionals and the demand for services in a base year and  predict how each will change in the future given expected changes in the  factors that affect supply and demand. On the supply side, “stock and  flow” models are commonly used; these models start with the current  number of health care professionals, add new entrants to the workforce,  such as students who complete their medical training, and subtract  providers who are expected to leave the workforce, such as those who  retire. Factors influencing supply include the capacity of educational  programs to train new health care professionals, the number of patients  that health care professionals are able to care for, and attrition rates. On  the demand side, a utilization-based approach is often used, which  measures the current utilization of health care services and projects that  pattern of utilization forward, making adjustments as the population  receiving services changes over time. Factors affecting demand include  economic conditions, population growth, and changing population  demographics such as aging or an increase in insurance coverage.
At the federal level, HRSA is responsible for monitoring the supply of and  demand for health care professionals and disseminating workforce data  and analysis to inform policymakers and the public about workforce  needs and priorities. To meet this responsibility, HRSA conducts and  contracts for health care workforce research to document and project  shortages and to examine trends that influence the supply and distribution  of health care professionals, as well as the demand for their services. In  2008, HRSA issued a physician workforce report containing national  supply and demand projections for physicians through 2020, which was  based on the agency’s physician workforce models: the Physician Supply  Model (PSM) and Physician Requirements Model (PRM). Using these  models, HRSA projected a shortfall of approximately 49,000 FTE  physicians by 2020.
The PSM is a “stock and flow” model, which projected the future supply of  physicians by taking the number of physicians from a base year (2000),  adding new entrants, and subtracting physicians lost through retirement,  disability, or death. The PSM projected both active supply (the number of  individual physicians) and the effective supply (the number of FTE  physicians accounting for the number of hours worked). The number of  FTEs was determined by the average number of hours worked for  physicians in each specialty by gender and age group.
The PRM is a utilization-based model, which projected the demand for  physicians starting with the utilization of health care services in 2000 by  age, sex, geographic location, and insurance coverage type (see fig.1).  The PRM assumed that supply and demand were in equilibrium in 2000,  that is, that there were enough physicians to meet the demand for health  care services. The PRM’s baseline projection also assumed that patterns  of utilization would not change, although HRSA created some alternative  scenarios showing how utilization might change (and therefore affect  demand) because of factors such as economic growth. HRSA also  included a scenario that accounted for the effect of nonphysician  providers, such as nurse practitioners and physician assistants, who may  offset the demand for physicians by providing services that otherwise  would have been provided by physicians. HRSA and others have noted  that a drawback of the utilization-based approach, which carries forward  current utilization patterns, is that when calculating the number of  physicians needed, any current imbalances in the system, such as  populations that may be underserved, or any overutilization of health care  services are also carried forward.
HRSA’s 2008 physician workforce report predates PPACA, which was  enacted in 2010. PPACA contains provisions that have the potential to  affect both health care workforce supply and demand, which increases  the uncertainty of health care workforce projections (see table 1). Several  health care workforce researchers have published estimates of the effects  of PPACA insurance coverage expansions on workforce supply and  demand. These studies found varying estimates for the number of  additional primary care providers required to meet the needs of the newly  insured population, ranging from 4,300 to 8,000 providers. The  variations in these projections are the result of differences in  methodologies and assumptions used in modeling. AAMC also increased  its overall projection of physician shortages for 2025 by 6,200 FTE  physicians, on the basis of expected increases in health care demand as  a result of greater rates of insurance coverage under PPACA, among  other factors. PPACA provides for the establishment of new delivery  models such as accountable care organizations (ACO) and patient- centered medical homes (PCMH). ACO models consist of integrated  groups of providers who coordinate care for a defined patient population  in an effort to improve quality, reduce costs, and share in any savings.  The PCMH model is a way of organizing and delivering primary care that  emphasizes comprehensive, coordinated, accessible, and quality care  built on strong patient-provider relationships. Such models also  encourage shifting care provision to nonphysician providers, potentially  decreasing the need for additional physicians. Some researchers have  stated that they expect new delivery models, such as ACOs, will have a  significant and lasting effect on the broader health care marketplace,  though research shows conflicting results as to how these new delivery  models will affect the supply of and demand for health care  professionals.
PPACA also mandated the establishment of the National Health Care  Workforce Commission and required HHS to establish the National  Center for Health Workforce Analysis (NCHWA) to collect and analyze  data on the health care workforce and evaluate workforce adequacy.  The National Health Care Workforce Commission was charged with  conducting analyses of health care supply and demand and submitting  annual reports to Congress that included recommendations. However,  this commission has not received appropriations and therefore has not  met since it was appointed. In 2010, HRSA established NCHWA within its  Bureau of Health Professions. NCHWA is responsible for developing and  disseminating accurate and timely data and research on the health care  workforce, among other things. In 2012, NCHWA produced a timeline for  updating HRSA’s workforce projections, as we recommended.
section_title: HRSA Has Taken Some Actions to Update National Projections, but Has Failed to Publish New Reports Since 2008
paragraphs: Since its last published report on physician supply and demand in 2008,  HRSA has initiated work to produce new workforce models and reports,  but has not published any new reports containing national workforce  projections. Specifically, HRSA has missed one of its publication goals for  new workforce projections and has created a revised timeline that  postpones future publications. Given that HRSA’s 2008 report was based  on 2000 data, the most recent projections available from HRSA to  Congress, researchers, and the general public to inform health care  workforce policy decisions are based on data that are more than a  decade old. From 2008 to 2012, HRSA awarded five contracts to three  research organizations to update or create new workforce projection  models, generate new national workforce projections, and produce  reports. (See table 2 for a summary of the contracts and their status.) As  of July 2013, HRSA had received three reports resulting from these  contracts, and two more reports were under development. Contractor A  delivered the first report, which includes projections for the primary care  workforce to 2020, in July 2010, but HRSA was still reviewing and  revising the draft as of July 2013. HRSA officials said that this primary  care report has required extensive consultation with other HHS  components to ensure that the methods used were consistent with other  ongoing workforce-related work within the department. In addition,  officials said that significant revisions were required to incorporate the  effects of PPACA. Contractor B delivered the second report, which  updated HRSA’s 2008 physician workforce projections using more recent  data, in February 2011. However, according to HRSA officials, the agency  decided not to publish this report because it did not incorporate  nonphysician providers, which they have since determined should be  accounted for when assessing the adequacy of the health care   However, officials also said that research conducted under  workforce.this contract regarding the health care workforce effects of PPACA was  incorporated into HRSA’s later projection models. The third report, the  clinician specialty report, which projects the supply of and demand for  health care professionals by specialty through 2025, was delivered in  November 2012 and is still under HRSA’s review.
HRSA has missed one of its timeline goals for finalizing its review and  publishing new reports containing national projections and has created a  new timeline that postpones publication dates for this and two other  health care workforce reports. Although HRSA’s original timeline stated  that the clinician specialty report would be published in December 2012,  HRSA’s revised timeline states that this report is expected to be  published in the summer of 2014. The revised timeline also included new publication dates for HRSA’s report on the primary care workforce  and for reports based on its new microsimulation models. (Table 3 shows  HRSA’s original and revised timelines for publication.)
HRSA attributed the delay in publishing the clinician specialty report to  data challenges and modeling limitations. For example, HRSA officials  cited limited research and data on the effects of new health care delivery  models being funded and tested in response to PPACA. HRSA officials  told us that new models such as ACOs and PCMHs have not yet been  studied adequately to know whether they will increase or decrease the  demand for health care professionals. It may be several years before  relevant data are available. According to a health care workforce  researcher we interviewed, there is going to be an inevitable lag in  obtaining data given that some delivery system models, such as ACOs,  are still being set up, and time will be needed to collect and analyze data  and publish any findings. In addition, other researchers have pointed out  that workforce-relevant data are not being systematically collected from  new models being supported and tested in response to PPACA. HRSA  officials also have cited challenges due to limited research on  nonphysician providers. For example, more research is needed to  determine how much nonphysician providers offset the demand for  physicians across different specialties. In our review of HRSA’s clinician  specialty models, we observed that for some specialties, the addition of  nonphysician providers has the potential to turn projected shortages into  surpluses. Another challenge HRSA officials said they need to address  stems from an inherent limitation of utilization-based models, namely, that  they project forward the utilization patterns of the past and therefore do  not adequately account for rapid changes in the health care system.  HRSA officials said that this modeling limitation has caused surpluses  and shortages that do not reflect anticipated workforce trends and require  time to analyze. For example, officials explained that when a provider  specialty is in shortage, utilization is by definition low. If investments are  made to increase the supply of the specialty in shortage, then the model  carries forward the past low utilization and incorporates increased  provider supply, which consequently projects a surplus for the future  because there will be more providers than were utilized in the past.
HRSA officials said that the agency does not have a standard written  work plan or set of procedures for accomplishing the tasks necessary to  prepare a report for publication after final reports are delivered from  contractors. Officials said that although there are general policies that  guide review, the specific steps of the review process and which internal  and external officials participate are determined on a case-by-case  basis. In addition, officials said that it is common for milestone dates to  change depending on the complexity of the issues raised during review.  According to HRSA officials, the dates included in their timeline were  based solely on when they expected to receive models and reports from  contractors and did not account for the continued analytical work involved  in reviewing delivered products. For example, according to HRSA  officials, the original 2013 goal dates for publishing reports based on the  new microsimulation models had to be postponed until 2014 because  they will require additional time to review after they are received. Without  standard procedures, agency officials may not be able to accurately  predict how long products will take to review or to monitor their progress  through the review process to ensure they are completed in a timely  manner. However, HRSA officials have stated that once the  microsimulation models are completed, these models will offer the ability  to more easily update projections as new data become available and  should result in more routine and frequent reporting.
section_title: Conclusions
paragraphs: The federal government has made significant investments in health care  professional training programs to help ensure that there is a sufficient  supply of health care professionals to meet the nation’s health care  needs. Health care workforce projections play a critical role in providing  information on future shortages or surpluses of health care professionals  so that policies can be adjusted, including targeting health care training  funds to the areas of greatest need. We recommended in 2006 that  HRSA, as the federal agency designated to monitor the supply of and  demand for health care professionals, develop a strategy and establish  time frames to more regularly update and publish national workforce  projections for the health professions. While HRSA created a timeline for  publishing new projection reports in 2012, the agency has since revised  its timeline to postpone publication of two other health care workforce  reports after failing to meet its December 2012 publication goal for a  clinician specialty report projecting the supply of and demand for health  care professionals through 2025. Other reports that have been delivered  by contractors since HRSA published its last report in 2008 have either  been set aside or are still being reviewed. In the case of the primary care  workforce report containing projections to 2020, review has been ongoing  for 3 years. If this report were published in 2013, it would project only   7 years into the future. HRSA itself has stated that physician workforce  projections should be completed at least 10 years in advance to provide  enough time for policy interventions to influence the size and composition  of the workforce. In the absence of published projections, policymakers  are denied the opportunity to use timely information from HRSA to inform  their decisions on where to direct billions of dollars in training funds. It is  also important to update projections on a regular basis so that changing  circumstances, such as the enactment of PPACA or the growth in  nonphysician providers, can be incorporated. Currently, the most recent  projections available from HRSA are based on patterns of utilization and  care delivery in 2000, predating PPACA by a decade. HRSA is now  making larger financial investments in new workforce projection models,  but in the absence of standard written processes specifying how the  reports resulting from these models will be reviewed, HRSA may be  hindered in its ability to monitor the development of these reports and  ensure that they are published in keeping with its revised timeline.
section_title: Recommendations
paragraphs: We recommend that the Administrator of HRSA take the following three  actions:
Expedite the review of the report containing national projections to  2020 for the primary care workforce to ensure it is published in the fall  of 2013 in accordance with HRSA’s revised timeline.
Create standard written procedures for completing the tasks  necessary to review and publish workforce projection reports  delivered from contractors; such procedures may include a list of  necessary review steps, estimates of how long each step should take  to complete, and designated internal and external reviewers.
Develop tools for monitoring the progress of projection reports through  the review process to ensure that HRSA’s timeline goals for  publication are met.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for review. HHS’s comments are  reprinted in appendix I. HHS also provided technical comments, which we  incorporated as appropriate.
In its comments, HHS agreed with our recommendations and described  actions that the department is taking to implement them. In response to  our first recommendation to expedite the review and publication of a  report containing primary care workforce projections, HHS said that it  expects to release the report on schedule in the fall of 2013. Regarding  our second recommendation to develop standard written procedures for  report review, HHS said that HRSA has developed a framework for report  development based on project management principles that is being made  available electronically to all HRSA employees. According to HHS, this  framework facilitates planning and provides guidance throughout the  report development process. Concerning our third recommendation to  develop tools for monitoring the progress of reports through the review  process, HHS said that HRSA has created a computer-based tool  capable of generating estimated time ranges for completing each step in  the report development and review process, which it anticipates will allow  for better oversight of report timelines. In addition to these agencywide  efforts, HHS said that BHPr is in the process of developing a review  process specifically for proposed workforce studies and contracts that will  emphasize more comprehensive review in the early stages of  development with the aim of reducing the time needed for final report  review.
In addition to addressing our recommendations, HHS commented that our  draft report did not discuss a number of other workforce-related activities  undertaken by NCHWA, such as data collection efforts and the production  of reports that do not include national projections. For example, in 2012  NCHWA fielded a survey to collect nationally representative data on  nurse practitioners. While we agree with HHS that such activities are  important, they are not a substitute for regularly producing updated  national projections. We did not include information in this report on other  HRSA reports not containing national projections, or HRSA's data  collection efforts, because the scope of our review was limited to national  projections of the supply of and demand for physicians, physician  assistants, and APRNs.
As arranged with your office, unless you publicly announce the contents  of this report earlier, we plan no further distribution until 30 days after its  issuance date. At that time, we will send copies of this report to the  Administrator of HRSA and other interested parties. In addition, the report  will be available at no charge on the GAO website at http://www.gao.gov.
If you or your staff members have any questions, please contact me at  (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. Major contributors to this report are listed in appendix II.
section_title: Appendix I: Comments from the Department of Health and Human Services
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Martin T. Gahart, Assistant  Director; Hannah Locke; Elise Pressma; and Jennifer Whitworth made  key contributions to this report.