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Tab8
This section includes:
Allied Health Professionals
Bernstein S et al. Health Personnel in the United States, Eighth Report to
Congress 1991: Allied Health. Bureau of Health Professions (September 1992)
(excerpts).
Allied Health Services: Avoiding Crisis. Institute of Medicine, Nat'l Academy
of Sciences 1989.
Chapter 5: The Role of Educational Policy in Influencing Supply.
Chapter 7: Licensure and Other Mechanisms for Regulating Allied Health
Personnel.
Clare DR et al. Health Professions Education For The Future: Schools in
Service to the Nation. Report of the Pew Health Professions Commission
Febmary 1993: 33-45.
�SUMMARY
Bernstein S et al. Health Personnel in the United States, Eighth Report to Congress 1991:
Allied Health. Bureau of Health Professions (September 1992) (excerpts).
This report provides the current legislative definition of allied health and discusses supply,
training, and school enrollment for several professions. The report identifies several problem
areas: (i) a worsening shortage of personnel, faculty and researchers; (ii) reductions in
enrollment and program closures; (iii) lack of diversity; and (iv) the effects of financing policies.
Allied Health Services: Avoiding Crisis. Institute of Medicine. Nat'l Academy of Sciences 1989.
Chapter 5: The Role of Educational Policy in Influencing Supply.
Chapter 7: Licensure and Other Mechanisms for Regulating Allied Health Personnel.
This study is intended to answer several questions: How will allied health workers fit into a
changing health care delivery system over the next 15 years? How can public and private policy
makers ensure that the demand for allied health personnel is met? Should these occupations
be regulated and, if so, how? What actions should educators take to prepare alhed health
practitioners for the workplace of the future? The commission concludes that growth of allied
health will be substantial and committee encourages educators to foster students' interest in
allied health careers. The committee also recommends that states strengthen systems of public
accountability and broaden their regulatory statutes and procedures.
Chapter 5 argues that the current system of allied health education is not sufficient to produce
the numbers of allied health workers who will be needed in the future. Three areas are
discussed: (i) pohcies that influence the decisions of persons choosing careers; (ii) the role of
educational institutions in adjusting enrollment; and (iii) the preparedness of the allied health
workforce.
Chapter 7 reviews the advantages and disadvantages of state regulation, federal regulation and
private control mechanisms in determining the appropriate roles of allied health personnel.
The chapter makes recommendations with respect to statutory certification and other regulation
for the protection of the public.
Clare DR et al. Health Professions Education For The Future: Schools in Service to the
Nation. Report of the Pew Health Professions Commission February 1993: 33-45.
The Commission makes six recommendations to educators, professionals and policy makers at
the state and federal levels. One. explore models for unifying parts of the allied health
professions in chnical service and education. Two, encourage continuous validation of clinical
practice in allied health. Three. improve the linkages among allied health practitioners and
within allied health education. Four, develop, test and evaluate new ways of utilizing allied
health workers. Five, provide for institutional accreditation for allied health programs. Six.
broaden efforts to enhance minority representation in allied health.
�HEALTH
PERSONNEL
IN THE
UNITED STATES
Eighth Report to Congress
1991
ALLIED
HEALTH
September 1992
U. S. DEPARTMENT OF HEALTH & HUMAN SERVICES
Public Health Service
Health Resources and Services Administration
Bureau of Health Professions
�177
Allied Health
Prepared by Stuart Bernstein and Dr. Marcia Brand, Division of Associated and
Dental Health Professions, BHPr.
Introduction
No universally accepted definition exists for
allied health care personnel. The Committee on Allied
Health Educadon and Accreditation (CAHEA) of the
AmericanMedicalAssocianon,whichaccreditsnearly .
3,000 education programs, defines alhed health practitioners as a "large cluster of health care related
professions and personnel whose functions include
assisting, facilitating, or complementing the work of.
physicians and other specialists in the health care
system, and who choose to be identified as allied
health personnel." CAHEA further notes that definitions of alhed health vary due to the changing nature
and differing perspectives of those who attempt its
definition, and because certain medically related but
traditionally parallel or independent occupations prefer identities independent of allied health.
a graduate degree in pubhc health, a graduate degree
in health administtation, a degree in clinical psychology or social work, or a degree equivalent to one of
these.
Estimated Number of Allied
Health Personnel
Alhed health has been and continues to be one of
the fastest growing occupational sectors. The Bureau
ofHealth Professions (BHPr), for program andeducational assistance purposes, has narrowed the definition
of alhed health into those components that require
professional training at the post-secondary school
level. Under this morerestrictivedefinition it is estimated that there were approximately 1.8 milhon allied
health personnel in the United States in 1990, an
The current legislative definition (Section 701 of
increase of 44 percent since 1980 and 144 percent
PHS Act) identifies an allied health professional as a
since 1970.
health professional who: (1) has received a certificate,
associate's, bachelor's, master's, ordoctoral degree or
Changes in the strucmre of the health care induspostbaccalaureate training in a science relating to try and the methods of its dehvery have resulted in an
health care; (2) shares responsibility for delivery of expansion of the role of alhed health personnel. As a
health or related services including services relating to result much emphasis has been placed on training and
the identification, evaluation, and prevention of dis- practice standards. In addition, because alhed health
eases and disorders; dietary and nutrition services; personnel play an integral role in the delivery of health
rehabilitation services; or health system management services, it is important, to consider the impact of
services; and, (3) has not received a degree of doctor changes in the population's health status and the health
of medicine, osteopathy, dentistry, veterinary medi- care industry at large on the training, supply, and need
cine, optometry, podiatry, chiropractic, or pharmacy. for these personnel
Health Personnel-1991
Allied Health
�178
figure 62
Allied Health Personnel Employed
by Type, 1970 to 1990
Therapy Personnel
Dietary Personnel
Radiology Personnd
EMT/Paramedic
Personnel
100,000
;/
.1970
1980
200,000
300.000
1990
Source: HRSAIBHPrlDADHP
Clinical Laboratory
Personnel
The 1988 Report to Congress on the Studv of
thcRole of Allied Health Personnel in Health Care
Delivery by the Institute of Medicine (IOM) provided
valuable infonnation about the composition of the
allied health workforce and its changing characteristics. This study assessed the role of allied health
personnel in health care dehvery and projected the
availability of, and requirements for, various types of
allied health personnel within specific health care
delivery sectors. It also assessed the role of Federal,
State, and local governments, educational institutions,
and health care facilities in meeting personnel requirements.
Allied Health
Introduction. Clinical laboratory personnel perform a wide variety of tests on body fluids,tissues,and/
or cells to aid in the detection, diagnosis, and treatment
of diseases. The medical technologist is the generalist
in this field, which also includes many specialty areas
such as blood bank technology, cytotechnology, hematology, histology, microbiology, and clinical chemistry. Practitioners fall into two broad categories:
associate degree and certificate-prepared technicians
and baccalaureate-prepared technologists. Generally,
^technicians perform routine tests under the supervision
. or direction of pathologists or other physicians, scientists, or experienced medical technologists. Technolo-
Health Personnel-1991
�179
gists are able torecognizeinterdependency of tests and
have knowledge of physiological conditions affecting
test results that allows them to confirmresultsand
develop data useful to a physician in determining the
presence, extent, and, as far as possible, the cause of
disease.
Developments in Supply
The ASCP and AMT maintain data on the number of persons who have applied and achieved certification orregistrationby having met certain professional standards. According to the ASCP, 184,000
technologists and 43,200 technicians were registered
as of 1990. AMT has registered 16,500 medical technologists, medical laboratory technicians, and medical assistants as having met guidelines for certification. .
; • • - V.. •
Current supply estimates of clinical laboratory
personnel are available from both the Federal Government and private professional associations. The Bureau of Labor Statistics* (BLS) Current Population
Survey (CPS) estimates that 297,000 persons were
employed as clinical laboratory technologists and
technicians in 1990. In comparison the BLS Occupational Employment Statistics survey (OES) estimates
that there were 258,000 positions employing these
personnel in 1990, of which 60 percent or 150,000
were located in hospitals (BLS, 1991). The American
Hospital Association (AHA) estimated that there
were 164,467 full-time equivalent clinical laboratory
personnel employed in hospitals 1989. The AHA
figure is higher than the OES' hospital estimate because it combines medical laboratory technologists
and technicians with other laboratory personnel who
perform supervisory and other supporting roles within
the lab.
. In 1990 the ASCP surveyed 2^00 medical laboratory directors requesting infonnation on vacancy
and wage rates forfiveseparate categories of laboratory personnel: medical -.technologists,
cytotechnologists, histologic technicians/technologists,
medical laboratory technicians, and phlebotomists.
The 1990 vacancy rate was higher than that reponed
in 1988 when a similar survey was conducted. In 1990
the highest vacancy rate was reported for staff
cytotechnologists (27.3 percent), more than double
thatreportedin 1988. Other positions in which
vacancy rates were greater than 10 percent include
staff medical technologists, histologic technologists,
medical laboratory technicians, and phlebotomists.
According to the ASCP survey the median beginning
wage paid to staff medical technologists was $22,100
per year in 1990, with some laboratory personnel
earning more than $30,600. Between 1988 and 1990
the beginning wage rate increased 11.3 percent and the
top rate increased 13.4 percent Rates of increase for
other disciplines in the medical laboratory are similar.
The clinical laboratory field has a number of
certifying agencies and associations. Though voluntary, certification may be a prerequisite for employment or career advancement in some settings. Among
the certifying bodies are the Board of Registry of the
American Society of Clinical Pathologists (ASCP),
the American Medical Technologists (AMT), the
National Certifying Agency for Medical Laboratory
Personnel, and the Credentialing Commission of the
International Society for Clinical Laboratory Technology.
'
In the University of Texas Medical Branch's
1990 National Survey ofHospital and Medical School
Salaries. 16 hospitals, 14 medical schools, and 33
medical centers supphed informationregardingsalaries for clinical laboratory personnel. For
cytotechnologists the actual weighted average salary
was $28,535 in 1990. Medical technologists were
compensated at similar levels, having a weighted
average of $28,343. For medical laboratory technicians the weighted average was $20,493 and for
histologic technicians it was $22,916.
Health Personnel-1991
Allied Health
�180
Training. Training requirements in this field
differ by position. Technologists generallyrequirea
baccalaureate in medical technology or one of the life
sciences; technicians are prepared at the associate or
certificate level, though some may obtain their training
on the job. Most clinical laboratory personnel axe
trained in collegiate programs or in clinical training
programs of hospitals, clinics, and blood banks requiring post-secondary academic preparation. The Council of Allied Health Education and Accreditation
(CAHEA) is the major accrediting body. -
1
reate graduates. During the same time period tot?
certificate medical laboratory technician progra.
declinedfrom57 to 41 and programs at the associate
degree level decreasedfrom221 to 215. Total enrollment for both types of accredited medical laboratory
technician programs declined 11 percentfrom7,455
in 1984to 6,668 in 1989. The numberof graduates for
both types of technician programs also declined 42
percent,from3,954 in 1984 to 2^92 in 1990.
:
'. CAHEA reported that in 1989-90 males represented about 25 percent of students enrolled in mediEnrollments and Graduates^ Data on enroll- cal technology programs, about 24 percent of those in
ments and graduations are available only for CAHEA associate-level technician programs, and 38 percent
accredited programs which, though important, does of those in certificate programs. " Minorities comnot accredit all programs in this field. As noted, not all prised 21 percent of enrollees in program s formedical
clinical laboratory personnel are prepared in accred- technologists; 12 percent were black and 9 percent
ited programs. Some may graduate with a degree in were Hispanic. In programs for medical laboratory
one of the laboratory sciences orfiomnon-accredited technicians 11 percent of the students were black, and
6 percent were Hispanic. In certificate programs, 17
programs.
-percent were black and 3 percent were Hispanic.
Between 1984 and 1990, CAHEAreporteda 32
percent decrease in the number of accredited programs
Trends in Medical Laboratory Worken. A
for medical technologists. Furthermore, the number major development in thisfieldover the past decade
graduatingfromsuch programs declined 30 percent has been the continued growth of testing in commr
since 1984 from a little over4,350 to 3,024 baccalau- cial laboratories and physician's offices. As a resuu
Figure 63 '."
Medical Laboratory Personnel i n the United States
Thousands
30025020015010050-
Number
Employed
: 1970
1980
1990
Source: HRSAIBHPrlDADHP
•Allied Health
Health Personnd-1991
�181
the demand for technologists and technicians in these
A1989 survey of clinical laboratory managers by
senings continues to be strong. Funhermore, demand the American Society of Medical Technology refor trained personnel may increase substantially as a ported a shonage of personnel in a numberof regions
result of legislanon toregulatephysician office labo- of the country. Funhermore, 67 percent ofthe respon
ratories that will set minimum standards for these dentsreportedthat it was much more difficult to hire
technologists in 1989 than in 1983 and 45 percent
personnel
noted more difficulty in hiring technicians. Factors
Demand is expected to grow in the hospital such as competition fair applicants, stress, lack of
sector. After a period of decline from 1982-1986, desirable working hours, and relatively low salary
employment of technologists and other laboratory levels contributed to the difficulty in hiring.
personnel appears to berising.In fact, in 1989, FTE
employment of medical technologists in hospitals
reached 90,564, just shon of its peak of 90,714 in
1982.
Physical Therapy
Demand for Clinical Laboratory Services. The
BLS projects a growth of63,000 new jobs for clinical
laboratory technologists and technicians between 1990
and the year 2005. Thisrepresentsa 24 percent
growth, about as fast as the 20 percent growth projected for all occupations as a whole. Demand for
medical and clinical laboratory technologists and technicians is affected by general expansion of the health
care industry, the aging of the populanon, and an
increase in such trends as therapeutic drug monitoring,
testing for substance abuse, AIDS screening, and
technological innovations that allow for the development of more precise and new tests. In addition to the
projected 63,000 new jobs, additional clinical laboratory technologists and technicians will be needed to
fill positions of those who haveretiredor left the field
for other reasons.
Introduction. Physical therapists evaluate and
treat patients with movement dysfunctions such as
thoseresultingfromaccidents, trauma, stroke, multiple sclerosis, cerebral palsy, nerve injuries, amputations,fractures,arthritis, and hean and respiratory
diseases. Their goal is to prevent, detect, eliminate, or
minimize pain and physical dysfunction. Physical
therapists provide in-patient, out-patient, and community-based services for patients, and educate family
members to provide therapy at home.
Developments in Supply. The BLS found that
there were 88,000jobs for physical therapists in 1990,
with hospitals having about 26,000 jobs, or about 30
percent of total jobs. Other major employers include
private or group practice (22 percent), physicians
offices (6 percent), home health care (5 percent), and
Although an assessment of the current and future nursing homes (4 perc jr..,. The AHAreponedthat
• balance between supply and demand cannot be made . full-time-equivalent employment of physical therawith certainty, recent data collected by the American pists in hospitals increasedfrom16,900 in 1981 to
Society of Clinical Pathologists (ASCP) indicate a 21,500 in 1989. This is a 27 percent increase,
high level of unfilled technologist positions in hospi- substantially greater than the 7 percent growth in total
tal-based medical laboratories. In addition to the hospital employment over the same time period. While
reponed high level of unfilled positions, ASCP also BLS and AHAfiguresare close, they differ somewhat
reponed that, based on their surveys, more than three- that BLSfiguresrepresentthe total number of jobs
in
fourths of laboratory managers perceive a shonage of in hospitals while AHA data represents full-time
laboratory personnel in their community.
equivalent employment. The American Physical
k
Health Pereonnel-1991
Allied Health
�182
Therapy Association (APTA) estimates the numberof
licensed physical therapists to be about 71,000 in
1990. About 25 percent ofphysical therapists are men,
although there has been some decline in this proportion in recent years. Approximately 10 percent are
from minority groups.
CPS datafromBLS shows that about 80 percent
of all physical therapists worked full time in 1988.
According to the APTA about two-thirds ofphysical
therapists were full-time salaried personnel An increasing proportion, 22 percent as of 1990, have
mastersdegreeswithabout7percenthavingamasters
degree as an entry-level degree.' - ^ - . ~ ,
,
assistant programs, most academic administrators
port having more than an adequate number of apphcants and can limit enrollment to those witb relatively
high grade-point averages. The positive economic
outlook for physical therapy-rising salaries, growing
autonomy, and high demand for graduates-appears to
account for the adequate supply of applicants. In 1990
those programs graduated 4,240 students, up 21 percent fiom 1985 and 73 percent from 1980.
Physical Therapy Assistants
r
The 1990 University of Texas Medical Branch
Introduction. Physical therapy assistants prosurvey found that the median annual earnings of vide physical therapy services under the direction and
physical therapists in hospitals, medical schools, and supervision of a physical therapist. Under proper
medical centers, was $32,364 in 1990. According to supervision, physical therapy assistants treat patients
the APTA the 15 percent of the workforce who are according to a plan of care, train patients in exercises
self-employed grossed nearly $73,000 on average in and activities of daily living, use special equipment,
1986while full-time salaried physical therapists aver-administer modalities and other treatment procedures,
aged $32,000. The gross income of self-employed andreponto the physical therapist on the patient's
workers is not comparable to wages of salaried em- response. Where permitted by law, physical there
ployees because practice expenses are included.'
assistants may also supervise physical therapy aides or
Training. All States, the District of Columbia, their equivalent and document a patient's progress.
and Pueno Rico have licensure laws governing the
practice of physical therapists. Professional preparation for physical therapists is typically obtained in
bachelor's or master's degree programs accredited by
the APTA's Commission on Accreditation in Physical
Therapy Education. In recent years an increasing
numl IT of entry level bachelor's degree programs
have become master's programs in order to teach the
expanding body of knowledge that students must now
leam. If the trend continues it may not be long before
themaster's degree becomes the minimum entry-level
requirement. In 1990there were 131 accredited entrylevel programs, 14 more than in 1986, and 83 more
than in 1970.
Enrollments andGraduates. Unlike other allied
. health disciplines, physical therapy has had no shortage of applicants. Despite a large increase in the
number of physical therapy and physical therapy
Allied Health
Physical therapy assistants practice in a variety of
settings that include hospitals, ambulatory care facihties, private practice,residentialfacilities, pediatric
facilities, home health agencies,rehabilitationcenters, and orthopedic and sports physical therapy centers.
Developments in Supply. According to the BLS,
in 1988 there were 45,000 jobs for physical therapy
assistants and aides. AHA data show 16,200 physical
therapy assistants and aides were employed on a fulltime equivalent basis in U.S. hospitals in 1990, a 9
percent increase since 1981.
Training. Physical therapy assistants receive
training from 2-year associate degree programs that
are accredited by the Commission on Accreditation in
Physical Therapy Education. The course of study
Health Personnel-1991
�183
includes liberal aits; basic, applied, and social sciences; and clinical experience. The licensure that is
required in many States stipulates specific educational
and examination criteria.
fromrehabihtationto health maintenance. The BLS
projects that the number ofjobs for physical therapists
will increase by 76 percent between 1990 and 2005,
making it the fifth fastest growing occupation.
Enrollments and Graduates. There were 104
accredited physical therapy assistant education programs in 1990. lhe number of programs increased 55
percent between 1985 and 1990 and 20 percent between 1980 and 1985. In 1990 there were 1,431
graduatesfiom73reportingprograms.,-
The supply of physical therapists is also expected
to increase as the growing demandforphysical therapy
services provides well paying job opportunities and
the promise of increasing autonomy. The latter has
been made possible by the fact that many States now
allow physical therapists to evaluate and treat padents
without a physicianreferral,thus allowing many
physical therapists to be directlyreimbursedby thirdparty payers. For instance, workmen's compensation
covers much of the expense for testing and therapeutic
treatment by physical therapists. Moreover, Medicare
now covers home visits and treatments provided in
both inpatient and outpatient settings.
• Trends in Physical Therapy, Several forces
support the "expectation that both the supply and
demand for physical therapists will grow. Demand for
physical therapy is expected to increase as the rehabihtation needs of a growing andagingpopulation expand
and as medical advances allow more disabling conditions to be treated. Already the elderly consume over
20 percent ofphysical therapy services, although those
65 and older are only 12.6 percent of the population.
In addition,rehabihtationneeds are expected toriseas
the baby boom generation enters the age ofriskfor
heart attacks and stroke. Also adding to the demand
for physical therapists is the expansion of their duties
Table 17
mmm
IBIilpiRelaitive I^mcsi-i9
''J£ZZ£
'$,'•
-u
V, »n,i«
•|n.i.,n,™->i i
M
Physical Therapy
Occupational Therapy
..mi.nmi. >.••.in '
$32,364
r_ ;ech Pathology/Audiology
31,580
Occupational Therapy
30,451
Medical Technologists
28.000
Dietitians
27.268
Medical Laboratory
Technicians
20,493
Source: BLS unpublished datafromthe currenl
population survey.
Health Personnel-1991
Currendy, there are not enough physical therapists to meet demand. Indicators of this include the
high proportion of funded, but unfilled positions and
the amount of time needed to fill them. Practice
settings experiencing the greatest difficulties filling
positions include hospitals, schools, nursing homes,
rehabilitation centers, and home health agencies.
Introduction. Occupational therapists help physically, mentally, and emotionally disabled individuals
develop the skills necessary to diminish or correct
pathology, perform daily living and work skills, and
promote and maintain health. Their goal is to enable
individuals to live as independently and productively
as possible by helping patients develop or redevelop
the skills needed to perform such daily activities as
bathing, dressing, cooking, eating, and working.
Developments in Supply. Occupational therapists work in a variety of settings. According to the
BLS there were about 36,000 jobs for occupational
therapists in 1990. The major employers included
hospitals (40 percent), schools (13 percent), social
Allied Health
�184
^^ervice s (8 percent), and private and group practices (8
percent). Tbe AHA reported that employment of fulltime-equivalent occupational therapists in hospitals
increased fiom 8,000 in 1981 to 12,200 in 1990. This
is a S3 percent increase, substantially greater than die
7 percent growth in total hospital employment over the
same time period. As with physical therapists, BLS
figuresrepresentthe total number of positions while
AHA data are full-time-equivalent positions.
_' The American Occupational Therapy Association (AOTA) estimated an occupational therapy
workforce of about37,600 in 1989. The vastmajority
^ of occupational therapists are female with a median
" age of 32. More than 70 percent work full-time (at
least 30 hours per week) and about 25 percent are selfemployed. About three-quarters of all occupational
therapists work in direct patient/client service. The
largest proportion of occupational therapists work in
private, nonprofit work settings (37 percent), followed by profit-making instimtions (27 percent), city/
^ounty (18 percent). State (13 percent), or Federal
ttings (4 percent).
•
Training. As of 1990,35 states, the District of
Columbia, and Pueno Rico had occupational therapy
licensure laws. To become licensed, individuals must
successfully complete an accredited educational program and pass AOTA's certification examination.
Two additional States (Kansas and Michigan) had
registration laws requiring competency standards, and
Wisconsin, had a voluntary certification law. In
addition, two States (California and Hawaii) have
mandatory certification ortitlecontrol acts that mandate entry-level competency and prohibits non-certified individualsfiomcalling themselves occupational
therapists. - - —-; - -. . •„ _
:•_ -,
;
The CAHEA accredits educational programs for
occupational therapists. Basic occupational preparation is offered in programs granting the bachelor's
degree, a post-baccalaureate certificate, or a master's
degree. The number of accredited programs has been
increasing. The AOTA's annual education survey
reponed 68 schools offering one or more occupational
therapy programs in 1989, up from 55 in 1982. Of the
68 schools, 64 offered baccalaureate degrees, 12 offered post-baccalaureate certificates, and 15 offered
entry-level master's degrees.
Forty-five percent of occupational therapists work
in urban areas, followed closely by suburban areas (40
percent), and rural areas (15 percent). Patients of
Enrollments and Graduates. In 1989 there were
occupational therapists are fairly evenly divided among 2,323graduates from programs offering basic occupathe various age groups. About 38 percent of occupa- tional therapy preparation, an 11 percent increase over
tional therapists work primarily with adults, a third 1981. Enrollment in these programs increased 17
work with children, and almost 29 percent work percentfrom6,825 in 1981-82 to 8,013in 1989-90. In
mostly with the elderly.
1989,256 graduates werefromentry-level master's
programs and 121 were from advanced post-profesAccording to a University of Texas Medical
Branch survey, the median annual earnings of occupa- sional master's degree programs. Almost two-thirds
tional therapists employed in hospitals, medical of occupational therapists and one-third of occupaschools, and medical centers was $30,451 in 1990. tional therapy assistants graduating in 1989 went to
Occupational therapists employed in school systems work in hospitals. School systems and nursing homes
are often classified as teachers and are paid accord- also employed additional numbers of new graduates.
ingly. The National Education Association reported
Occupational therapy will likelyremaina prethat during the 1988-89 school year elementary school dominantly female occupation in that only 9 percent of
teachers earned about $29,000annually while second- recent enrollments were male. Minority enrollments
ary school teachers earned about $30,293.
were also small, comprising 4 percent black, 3 percent
Hispanic, and 1 percent American Indian in 1989.
Alhed Health
Health Personnel-1991
�185
Occupational Therapy
Assistants
Trends in Occupational Therapy. Many of the
rehabilitative and long-term care needs projected to
drive growth in both the supply of and demand for
physical therapists also apply to occupational therapists. These include the aging of the baby boom
Developments in Supply. Occupational therapy generation, the rapidly growing number of aged who
assistants work under the supervision of registered sufferfromchronic debilitating conditions, and medioccupational therapists to cany outrehabilitationpro- cal advances that allow the provision of a greater
grams that help disabled persons leam orregaintheir numberof services. Also increasing demand is Fedabihty to lead constructive lives. Sixty-eight schools eral legislation diat expands services already provided
offered approved educational programs in 1990: 66 to handicapped children in schools.
offered associate degrees, 4 offered certificates, and 2
The supply of occupational therapists should also
offered both. The number of programs offering increase inresponseto the well paying job opportunidegrees for occupational therapy assistants has risen ties thatresultfromrapidly growing demand and from
steadily over the past two decades.
the greater professional autonomy that direct reimThe AOTA estimates there were 7,900employed bursement allows. The BLS projects that the number
occupational therapy assistants nationwide in 1990. ofjobs for occupational therapists will increase by 55
About 72 percent worked full-time and 17 percent percent between 1990 and 2005, much faster than die
worked pan-time. The remaining 11 percent are average 20 percent growth anticipated for all jobs in
retired, work as volunteers, or are temporarily out of the economy. A majorfactor tending to inhibit growth
the workforce at any giventime.More than 20 percent in the supply needed to meet this demand, however, is
work in nursing homes and 17 percent work in school the long lead time needed to develop new educational
systems. Other major work settings include general, . programs and tofindenough instructors to staff them.
rehabilitative, and psychiatric hospitals. Occupational
The AOTA estimates the current shortage of
therapy assistants can also be found employed in occupational therapists to be approximately 25 percommunity mental health centers, day care programs, cent
home health agencies, outpatient clinics, and other
faciUties. Almost 90 percent are in direct patient care.
Dietetic Services
About one-third of occupational therapy assistants work for private nonprofit agencies. A somewhat smaller proportion work for private, profitmaking facihties. The remainder work in city, county,
Introduction. Dietitians are concerned with die
State, or Federal facihties.
relationship between proper diet and health. Toward
that end dietitians are trained in nutrition and instituEnrollments and Graduates. According to
tional management and areresponsiblefor providing
AOTA 3,050 students were enrolled in occupational
adequate nutritional care including therapeutic nutritherapy assistant programs in 1989, a 7.9 percent
tion to individuals and groups. Major areas of practice
increase from the year before. Graduates exceeded
include clinical, community, and management dietet1,000 for the fint time in 1989,reaching 1,038, an 11.9
ics. Dietitians also work as educators and researchers
percent increase over the previous year. -
Health Personnel-1991
Allied Health
�186
Developments in Supply. Estimates of the size of expected the beyond-enoy-levelregistereddieritianr
dietetic workforce vary. The American Dietetic exhibited the broadest range of activities and had the
Association (ADA) estimated that there were 58,800 mostresponsibihtyfor pohcy setting and administraactive member dietitians in 1989. The BLS OES tive activities, such as preparing budgets.
survey estimates that there were about 45,000 jobs in
According to a University of Texas Medical
1990.
Branch survey the median annual salary for registered
AHA data indicates that there was a 4 percent
decline in full-time-equivalent employment of dietitians in hospitalsfrom14,400 in 1981 to 13,900 in
1989. Some ofthis may be due to an apparent tendency
for hospitals to contract wiih private companies to
provide food and dietetic services. Thus the employer
of dietitians may change, but not the employment
dietitians employed in hospitals, medical schools, and
medical centers was $27,268 in 1990. Dietitians
employed by the Federal govenunent earned an average of $32^86 in 1989, _ :
_ . ..
' Training. As of 1990,26 States had legislation
governing the practice of dietetics. Seventeen States
had licensure laws, eight had certification standards,
and onerequiredregistration.Students are now
The American Dietetic Association (ADA) re- trained as generalists with specialization in such areas
ports that over 60percent of theirmembers were under as community, clinical, or management dietetics avail40 years of age. The vast majority were women and able through graduate education. A baccalaureate is
relatively small percentages were of minority racial- the basic educationalrequirementfor dietitians. In
order to sit for the registration examination of the
ethnic background.
ADA, a baccalaureate with a clinical component is
The 1990 BLS data show hospitals and nursing required. As of 1990 baccalaureate training was
es were the two largest employers of dietitians, availablefrom242 colleges and universities. The
n
ploying 38 percent and 12 percentrespectively.An clinical component was availablefrom59 ComprePi survey shows that over one-half of its full-time hensive Programs, which include academic and clini•A
members were employed in hospitals and that one in cal training in a 4-year program; orfrom96 accredited
ten were employed by extended care facilities. The internship programs or 73 Preprofessional Practice
ADA survey also notes that only a small percentage of Programs. These last two programs require 900 hours
full-time workers were self-employed, but more than of post-academic clinical experience under the superone-third of pan-time workers were self-employed. vision of aregistereddietitian.
Employers such asretaileating and dining places,
pubhshers of nutrition books and periodicals, diet
Enrollments and Graduates. Between 1980 and
counseling services, child care centers, and food manu- 1987 the number of newly-registered dietitians fell 20
facturing also employ dietitians.
percent, from just over 3,000 to shghtly under 2,400.
According to the National Center forEducation StatisIn order to develop a current picture of the tics the number of bachelor degrees awarded from
dietetic profession, the ADA, with assistance from Food and Nutrition programs declined 14 percent
American College Testing, studied the roles of entry- from 3,354 in 1983 to 2,871 in 1988.
level dietetic technicians andregistereddietitians, and
Trends in Dietetics. Factors that must be
beyond-entry-levelregistereddietitians. The results
of anationwide survey showed that the most common included in determining the demand for dietitians
work setting for the threerespondentgroups was include: consumer desire for nutritional advice, the
inpatient-care, acute-care facihty." As would be abihty to pay for services, new places of employment.
«
4
4
Allied Health
Health Personnel-1991
�187
trends in substitution of other professionals, and interest in the relationship of nutrition to health promotion
and disease prevention for dietitians, lhe lOM's
Report to Congress on the Study of the Role of Allied
Health Personnel in Health Care Delivery concluded
that overall modest growth for dietetic personnel is
expected. Factors tending to increase demand include
high technology nutritional services, expected growth
in the hospitalization of patients with complex problems, and society's growing awareness of the importance of good nutrition.
Medical Record Personnel -
personnel are employed in hospitals but increasing
numbers are being employed in HMOs, nursing homes,
and group practices. Other medicalrecordspersonnel
are employed by insurance, accounting, and law firms
as well as companies that market medical record
information systems.
Certification is available though the American
Health Information Management Association
(AHIMA). Though voluntary, certification may be a
prerequisite for some jobs or necessary for career
advancement AHIMA" reported 9,927 registered
medicalrecordadministrators and 15,829 accredited
record technicians in 1990. Many personnel in lower
positions are trained on the job.
Introduction. Managing medical infonnation
systems that meet medical, administrative, ethical,
Training. Trainingrequirementsdiffer dramatiand legal requirements is the job of medical record
administrators, medical record technicians, and medi- cally between the differentlevels ofpersonnel. CAHEA
calrecordclerks known collectively as medical record accredits educational programs for medical record
personnel Medical record administrators direct the administrators and medicalrecordtechnicians. Mediactivities of the medicalrecordsdepartment, develop cal record administrator programs are 4 years in length
tracking systems for patients' records, compile statis- and award a bachelor of science degree or provide a
ticsrequiredby Federal and State agencies, and assist post-baccalaureate certificate, generally after 1 year
the medical staff in evaluating patient care. The of additional study. Medical record technician promedicalrecordtechnician isresponsiblefor handling grams are 2 years in length and lead to an associate
patient records,recordingand coding diagnoses, and degree.
organizing and evaluating records for completeness
and accuracy. Medicalrecordpersonnel often work
closely with financial departments to monitor spendEnrollments andGraduates. In 1990 there were
ing patterns and frequency of procedures performed. 713 graduatesfromCAHEA accredited programs for
Medical Record Administrators. The numberof graduates has fluctuated during the 1980s, having peaked at
Supply Trends. The Current Population Survey 896 graduates in 1986. The number of CAHEA
data from the Bureau of Labor Statistics data showed accredited programs in medicalrecordsadministra69,000 medicalrecordpersonnel employed in 1990. tion declinedfroma high of 57 programs in 1982 to 55
The AHA, which collects data on both medical recordprograms in 1990. During the same period the number
administrators and technicians, reported that there of CAHEA accredited medical record technician prowere 8,410 FTE administrators and 46,641 FTE tech- grams increasedfrom85 programs in 1982 to 102 in
nicians employed in hospitals in 1989, an employment 1990. The number of graduates in medical record
growth of 16 percent for administrators and 28 percent technician programs increasedfrom808 in 1982 to
for technicians since 1981. Most medical record 1,132 in 1990, a 40 percent increase.
Health Personnel-1991
Allied Health
�188
Figure 64
N u m b e r of Medical R e c o r d s A d m i n i s t r a t o r s
a n d T e c h n i c i a n s E m p l o y e d In the U . S . :
S e l e c t e d Y e a r s , 1970-1990
1970
•
. .
1080
Administrators
1990
Technicians
Source: HRSAIBHPrlDADHP
In addition, there is a National Home Study future jobs. Demand for medicalrecordpersonnel in
Course for qualifying individuals to become medical the year 2000 will be strong as the need for accura*
record technicians. This 3-year program, which in- and complete medical records becomes vital in i
cludes 30 semester hours of academic training, had an efforts to improve quahty of care and control health
enrollment of 3,230 students and graduated 268 in care costs.
1990.
"
Men continue to represent a small proportion of
enrollments in medicalrecordstraining programs. In Diagnostic Imaging
1989 menrepresented9 percent of enrollments in Personnel
administrator programs and S percent in technician
programs. Minorities represented a somewhat greater
share of enrollments in administrator programs with
Introduction. Radiologic technologists and tech19 percent being black, 4 percent Hispanic, and 1 nicians, nuclear medicine technologists, radiation
percent American Indian. Minorities in technician therapists, sonographers or ultrasound technologists,
programs included 13 percent black, 6 percent His- and magneticresonancetechnologists together companic, and 1 percent American Indian.
pose the group collectively known as diagnostic imagTrends in Medical Records Personnel. Accord- ing personnel. The use of images to help in the
ing to the lOM's Report to Congress on the Studv of diagnosis of injuries, diseases, or conditions began
the Role of Allied Health Personnel in Health Care with X-rays. Since that time medical and technologiDelivery, current trends indicate that the knowledge cal advances have generated a numberof new imaging
and skill level needed in medical records isrisingand techniques andresultedin the development of spewill continue torisein the foreseeable future, creating cialty occupations to perform these procedures. The
a greater need for persons trained to fill current and application of radioactive tracers has led to the profes
Allied Health
Health Personnel-1991
�189
Training. CAHEA, in collaboration with the
Joint Review Committee on Radiologic Technology
and the Joint Review Committee on Sonography,
accredits educational programs for radiographers, radiation therapists, nuclear medicine technologists,
and diagnostic medical sonographers. Programs in
radiography are generally 2 to 4 years in length and in
medical sonography 1 to 4 years in length depending
upon the objectives and the degree or certificate
•
Developments in Supply. According to the BLS awarded. .- •-•
Current Population Survey, approximately 122,000
Enrollments andGraduates. In 1990there were
persons were providing diagnostic imaging services in 672 programs in radiography that graduated 7,402
1990 (including radiographers, radiation therapists, students. Total enrollment in these programs was
nuclear medicine technologists, and diagnostic medi- nearly 18,700. The number of graduates of radiogracal sonographen). Recent data from the AHA show phy programs is about the same as it was 5 years
that the number of radiographers employed on a fulltime-equivalent basis in U.S. registered hospitals grew earher, reversing a period of decline.
17percemfrom53,662in 1981 to62,528 in 1989. The
The number of programs in radiation therapy
number of FTE radiation therapists grew 25 percent technology in 1990 was 104, the same as in 1985. The
fiom 4,007 to 5,001 during this period. Also duringnumber of graduates in academic year 1989-90 was
this time nuclear medicine technologists employed on 542, having declinedfiomthe peak of 576 graduates
a full-time-equivalent basis grew 10 percent fiom 4 years earher. Enrollment in these programs in
7,226 to 7,960 and other radiologic personnel in- academic year 1989-90was 962, about the same as the
peak enrollment level achieved 4 years eariier.
creased 10 percent from 32,025 to 35,286.
sion of nuclear medical technology, and the use of
megavoltage radiation equipment to treat cancer has
led to radiation therapy technology. In addition, the
use of sound waves in the development of ultrasound
imaging equipment has led to diagnostic medical
sonography, while the harnessing of radiowaves has
led to magnetic resonance technology.
Figure 65
Number of Radiologic S e r v i c e Workers
E m p l o y e d In the United S t a t e s :
S e l e c t e d Y e a r s 1970-1990
Thousands
140
1970
1080
1090
Source: HRSAIBHPrlDADHP
Health Pereonnel-1991
Allied Health
�190
The number of nuclear medicine technologist
igrams declinedfrom153 in 1979 to 107 in 1990.
The number of graduates declined 25 percent from
813 in 1984 to 611 in 1990. Total enrollment also
declined from 1,547 in 1984to 1,253 in academic year
1989-90, a 19 percem decline.
Speech-Language Pathology
and Audiology
Introduction. Speech-language pathologists and.
audiologists identify, assess, and provide treatment
Programs in diagnostic medical sonography
(DMS) werefirstaccredited in 1982. The number of fbr individuals with speech, language, or hearing
programs has increased from 6 in 1982 to the present disorders. Speech-language pathologists are special43. DMS programs vary in length fiom 12 months to ists in the understanding and expression of human
48 months depending upon the certificate or degree communication, its normal development, disorders,
awarded. The number of graduates has increased 135 and the prevention of disorders. Audiologists are
percent fiom a low in 1984 of 144 to the present high specialists in prevention^ identification, assessment
of 338. Total enrollment in DMS programs for and rehabihtation of individuals with hearing impairacademic year 1989-90 was 635, about 61 percent ments including the fitting and dispensing of hearing
aids. Through licensure 38 States regulate the practice
higher than the level of 4 years earher.
of speech-language pathology , and 39 States regulate
Males represent a relatively large proportion of the practice of audiology. •
enrollments. According to 1989-90 CAHEA data,
Developments in Supply. Data on the supply of
males represented 46 percent of enrollees in nuclear
Speech pathologists and audiologists are available
medicine technology, 28 percent in radiography, and
30 percent in radiation therapy technology. In terms fiom the BLS Occupational Employment Survey and
minority enrollment, blacks represented 5 percent the CPS. According to the OES survey, there were
enrollees in diagnostic medical sonography, 8 68,000 positions for speech pathologists and audiolopercent in nuclear medicine technology, 7 percent in gists in 1990. The CPS estimated the supply of
radiography and 9 percent in radiation therapy tech- employed speech pathologists and audiologists at
nology. Hispanics represented 9 percent of those 63,000 in 1990. In addition. The American Speechenrolled in nuclear medicine technology programs, 6 Language-Hearing Association (ASHA) reported as
percent in radiography and 4 percent in radiation of August 1990,57,264 members, of whom 75 percent
were employed.
therapy programs.
Based upon its 1990 membership survey, ASHA
reponed that the 1990 average annual income of
Demandfor Radiologic Personnel. The IOM members holding a master's degree was $31,580;
study predicted that even if the decline in graduations those with doctoral degrees averaged $52,440.
from radiologic education programs is stemmed, strong
In its 1988 workforce study, ASHA estimated the
adjustments in the labor market will be needed to avoid
a shortage of these personnel through the year 2000. active supply of personnel in the field as 83,100,
The 1990 CPS showed an unemployment rate of 2.3 approximately one-halfof whom were members of the
percent for radiologic technicians, less than one-half Association. The study found that ASHA and nonof the overall unemployment rate and below the ASHA personnel were similar in age, gender, marital
unemployment rate CAHEA has calculated for all status, race/ethnic background, and geographic distritechnicians and related support personnel combined. bution. However, almost all ASHA members had the
Seventy two percent of program directors believed master's degree as the highest degree while a substantial portion of non-members only had the bachelor's
that the supply of radiographers is inadequate.
degree. Employment characteristics of the two groups
Allied Health
Health Personnel-1991
�191
were also similar. Approximately three of four were
employed full-time, the median number of years
waked was at least 10 years, and over one-half were
employed by governmental agencies or organizations.
Three out of four non-members were employed in
school settings, compared to fewer than one-half of
members. In addition, clinical service provision was
reported as the primary professional activity for a
greater proportion of the non-ASHA group compared
with the ASHA group. "
percentin 1985-86, to7.1 percentin 1986-87, and then
to 8.5 percent in 1987-88. In 1987-88 States reported
a need for an additional 3,596 speech-language pathologists according to unpubhshed datafromASHA.
Factors that need to be monitored to track future
demand for persons in this field include Medicare
reimbursement ofrehabihtationservices; school systems growth andfinancing;patterns of specific diseases and treatment such as stroke, head trauma, and
deafness in youth; and growth in independent practice
The numberof speech-language-hearingperson- opportunities and contractual arrangements with freenel employed in hospitals is very small compared with standing speech-language pathology and audiology
other disciplines. AHAreportsthat 6,184 of these organizations. - —
personnel were employed on a full-time-equivalency
basis in 1989, a 60 percent increase since 1981.
;
Training. A master's degree in speech language
pathology or audiology is the standard credential
necessary to practice in this field although some States
permit individuals with a bachelor's degree to work in
the school system.
Enrollments and Graduates. Data from the
Council of Graduate Programs in Communication
Sciences andDisorders for the 1988-89 academic year
indicated that there were 8,445 master's degree students enrolled and 3,760 master's degrees awarded in
1987-88. In 1988-89 there were 15,758 undergraduate students compared with 15,088 in 1986-87, a 4.4
percent increase. Bachelor's degrees declined by 8.8
percent,from4,300 in 1985-86 to 3,923 in 1987-88.
The number of doctoral students in 1988-89 was 782.
In 1987-88,136 doctoral degrees were awarded.
Respiratory Therapy
Personnel
Introduction. Respiratory therapy personnel
work under the direction of qualified physicians. They
speci ah ze in the evaluation, treatment, and care of
patients with breathing disorders. Twenty-nine States
and Puerto Ricoregulaterespiratorycare through
licensure. Legislative action for licensure is anticipated in 13 more States in 1991.
Developments in Supply. According to the BLS,
in 1990 there were 60,000 positions in respiratory
therapy, 9 out of 10 of which were located in hospitals.
By comparison, in 1989 the AHA estimated a total of
Demand for Speech-Language-Hearing Per- 60,107 FTE positions, 37,184respiratorytherapists,
sonnel. Althought there is substantial need for the and 22,923respiratorytherapy technicians. The CPS
services of speech pathologists and audiologists, no estimated that 62,000 persons were employed in resestimates exist on the degree to which this need will be piratory therapy throughout all health care dehvery
translated into demand for services.
sectors in 1990. A1987 manpower survey conducted
According to the AHA the vacancy rate for by the American Association for Respiratory Care
speech-language pathologists in hospitals was 92 (AARC) suggested that more than 69,900 full-timepercent in 1988. Vacancy rate data for speech- equivalent personnel were engaged in respiratory care
in hospitals.
language pathologists in schools ranged from 8.1
Health Personnel-1991
Alhed Health
�192
Hie 1987 AARC manpower survey, conducted
by sampling hospital and school programs, has served
as a basis for informadon on respiratory care personnel. In 1991 the Association's Task Force on Professional Direction began phase one of a three-phase
survey that will attempt to identify every respiratory
care professional in the country. The initial effon is
designed to identify aU employers of respiratory care
personnel and then to acquire basic demographic
infonnation on practitioners they employ.
The National Board for Respiratory Care is the
credentialing agency for respiratory .care practitioners. Certification is voluntary, and as of year-end
1989,100379 individuals had received credentials to
administer respiratory care.
to be accredited by CAHEA, programs for respire
therapists must be at least 2 years in length and lea*.. _
an associate or bachelor's degree. Technician programs usually last 1 year.
Enrollments and Graduates. In 1990there were
2,830 graduates from 259respiratorytherapy programs and2,886graduates from 159respiratory therapy
technician programs. Although the numberof CAHEAaccreditedrespiratory therapy programs increased by
21 percent between 1982 and 1990, die number of
graduates declined by 15 percent from 3342 to 2,830.
During die same time period the number of CAHEA : accreditedrespiratorytherapy technician programs
declined 15 percentfrom188 to 159 while the number
of graduates declined 12 percentfrom3,275 to 2,886.
Training. The CAHEA accredits educational
According to 1989-90 CAHEA data, men repreprograms for bothrespiratorytherapists and respira- sented arelativelyhigh proportion of total enrolltory therapy technicians. Training is offered at the ments, 37 percent, in bothrespiratorytherapy and
post-secondary level in colleges and universities, respiratory therapy technician programs. The propormedical schools ..trade schools, and hospitals. In order tion of minorities enrolled was also fairly high; 13
Figure 66
N u m b e r of R e s p i r a t o r y T h e r a p y W o r k e r s
E m p l o y e d In t h e U n i t e d S t a t e s :
Selected Years 1970-1990
Thousands
80
1970
1980
1990
Source HRSAIBHPrlDADHP
Alhed Health
Health Pereonnel-1991
�193
percent of those enrolled in respiratory therapy and 17
percent of respiratory therapy technician enrollees
were black. The proportion ofHispanics was 7 percent
for respiratory therapy and 8 percent for respiratory
therapy technician.
TrendsforRespiratory Therapy Personnel. The
American Medical Association points to decreases in
the number of students graduating from respiratory
therapy programs as indicators of a potential shortfall
in the field. At the same time the BLS predicts that by
the year 2005 there will be 91,000jobs for respiratory
therapists - an increase of 52 percent over the present
level. This is a substantially higher growth iate than is
projected for total employment. Increases in the number of elderly who are more susceptible'to chronic
pulmonary diseases, improvements in trauma care that
allow the survival of more accident victims in need of
ventilator care, and the projected rapid growth in the
numberof patients with AIDS who prior to death often
contract pulmonary diseases, are all likely toresultin
increased demand forrespiratorycare services.
Figure 67
•" -
Forecasts of Growth in Selected Allied
Health Occupations, 1990 to 2005
71-
Allied Health Information
System
The Repon to C n r s on th* Study of the Ro
o ge s
pf Allied Hcallh Personnel in Health CarcPclivcry by
the IOM makes a number of recommendations for
improving alhed health data. In addition. Congress, in
itsrequirementfor an Alhed Health Information System contained in section 708(h)(1) of the Pubhc
Health Service Act, alsorecognizesthe paucity of
alhed health data. Specifically Section 708(h)(1) of
Tide VH of the Pubhc Health Service Act states that
the Secretary may make grants or enter into contracts
and cooperative agreements with and provide technical assistance to any nonprofit entity in order to
establish a uniform alhed health professions data
reporting system to collect, compile, and analyze data
on allied health professions personnel
To improve the availability of data, the BHPr has
been actively working with alhed health associations
through therecentlycompletedStrategicAlhedHealth
Data Initiative and other means such as the development of an allied health computer bulletin board.
Issues in Allied Health
Education and Practice
U ~
J
»
4
1
3
1
a
i
u
i
1
FtrttBlbmiM, mOtoMOS
-
OnnO
lacitnc
The allied health field faces a number of problems including growing shortages of personnel in a
number of critical professional categories, reductions
in enrollments, closures of training programs,
underrepresentation of minorities, and shortages of
faculty and trainedresearchers.Many of these problems are exacerbated by changes in working environments, the need to contain costs, the changing career
preferences of a new generation of students, and by
rapid growth in segments of the population utilizing
allied health services.
Source: BLS Monthly Labor Review, November 1991.
Health Personnel -1991
Allied Health
�194
•
Growing Shortage of Personnel. The IOM in its Compounding the losses incurred through progranr
epmt to Conpess on the Studv of the Role of Alhed closures arereportsof substantialreductionsin enrollHealth Personnel in Health Care Delivery stales that ments in training programs in manyfields.Although
large discrepancies between supply and demand for many educational programs experienced a significant
allied health practitioners have beenreportedin physi- drop in enrollment, there were increases in selected
cal therapy, radiologic technology, and occupational fields and there are preliminary indications that enrolltherapy. Most recendy, professional association ment declines may bereversing.Fbr example, the
newsletters have indicated that employers are experi- Commission on Dental Accreditation, which had reported declines in dental assisting enrollment of 15.5
encing increasing difficulties attracting and retaining
medical laboratory technologists. BLS data indicate percent in 1988, showed a \ 2 percent increase in
—
•
- '••
unemployment rates for therapists and laboratory enrollments in 1989.
personnel in 1988 are far below the national average.
V > -With the exception of physical therapy many
-•, Although the BLS does not make projections of alhed health disciplines are experiencing a decline in
shortages, it is important to note the rapid growth appUcations. In order to increase apphcants, it will be
expected for many of these occupations. Only two necessary to increase interest in alhed health careers
occupations, dietitian and clinical laboratory tech- early in the educational process and to seek students
nologists, are expected to grow at a rate considered to fiom less traditional apphcantpools—minorities, older
be as fast as the average for all occupations. The students, career changers, those already employed in
remaining occupations are projected to grow any- health care, and individuals with handicapping condiwherefiom14 to 56 percentage points faster than the tions.
20 percent growth projected for all occupations as a
TrendsinCollege Enrollment. Graduation from
;
2- or 4-year college programs is required as a condi
Difficulties infillingpositions for specific cat- tion of entry into most alhed health occupations. Thus,
egories of alhed health personnel are also seen on a trends in highereducation enrollment are critical to the
regional level. For example, the Metropolitan Chicagopotential labor supply of alhed health personnel and
Healthcare Council found in itsrecentannual survey declines in applications. Especiallyrelevantis the
of area hospitals that some of the highest vacancy rates dechne in the college-age population due to a decrease
reported were in alhed health: over 15 percent for in births rates over the last two decades. Such declines
physical therapists (greater than registered nurses), are expected to continue to 1996 when the pool of
over 7 percent for occupational therapists, and 6 eligible traditional college age candidates will be
nearly one-fourth below the 1980 peak. The coUege
percent for nuclear medical technologists.
population, and consequendy the pool of potential
Reductions of Enrollment and Program Clo- allied health supply, can only be maintained if a higher
sures. A factor in the shortage of certain types of alhed proportion of youths go to college or if non-traditional
health personnel is a decrease in the number of accred- groups are recruited. To bring this about requires
ited programs. Recent datafiomthe CAHEA, which significant changes in the criteria traditionally erpaccredited 2,821 educational programs in 26 alhed ployed for coUege admission as weU as a restructuring
health occupations in 1989, have shown a substantial of die ways in which alhed health professionals are
decline in die number of accredited programs. For trained.
example, the number of cytotechnologist programs
had declined by two-thirds in a 12-year period and
Minorities in Allied Health. The number and
radiographer programs by 27 percent In the academic proportion of minorities in many allied health fields
year1988-89 there were 28 fewer medical technologist remain small. According to 1989 CAHEA data 79
•grams accredited by CAHEA than in 1987-1988. percent of all students enroUed in CAHEA-accredited
Alhed Health
Health Personnel-1991
�195
programs were white, not of Hispanic origin, and 75
' Effects ofFinancing Policies. Thefinancingof
percent were female. Therecruitment,retendon, and health services influences the demandfor alhed health
graduation of minorities is a particular concern for a personnel, the location in which services are provided,
number ofreasons.Minoritiesrepresenta relatively and the type of provider. For example, laboratory
untapped source of manpower, and because they services, once viewed asrevenueproducers prior to
represent an increasing proportion of the population, the advent of prospective payment systems are now
it is critical that mechanisms be developed to increase considered cost centers and can result in significant
tberepresentationof minorities within the alhed health displacements of the alhed health work force.
workforce.
Faculty and Researcher Shortages. Shortages
of alhed health professionals may resultfrominadequate numbers of faculty. There is amplereasonto
expand the capacity ofbasic occupational preparation,
but the costs of estabhshing new programs and the
salary levels needed to attract qualified faculty are
discouraging to many academic instimtions. In physical therapy, a field that is experiencing serious shonages, there is substantial demand for training because
there are five apphcants for eachfirst-yearspace.
Expansion of training capacity in physical therapy is
in part constrained by a lack of qualified faculty.
Although the profession predicts that many additional
doctoral qualified faculty will be needed to teach in
entry-level education programs over the next decade,
such needs are unlikely to be met without faculty
training programs.
The accelerating pace of change in treatment
modalities that are driven by the introduction of new
technologies demands seriousresearch.All too often
clinical treaunent is guided by conventionratherthan
empirical assessment andresearch.Improved deploy. ment and utilization of allied health workers may
i require productivity studies. Clinical and systems
research in alhed health are almost non-existent, yet
these disciplinesrepresentnearly two milhon health
care providers. Somefieldsare only beginning to
developresearchleaders to build a body of knowledge
linked to a theoreticalframework.Arealneed exists
for enhancing theresearchskills of alhed health
faculty.
Health Personnel-1991
References
AmericanMedlcalAssodatlon. Division ofAllied Health.
Education and Accreditation. Allied H«dth Erinraitton
DlrectoTV. Eighteenth Edition. Chicago. 1990.
AmericanMedlcalAssodatlon. Division ofAllied Health
Education and Accreditation. Allied Health Educatten
DlrectoTV. Nineteenth Edition. Chicago. 1991.
American Occupational Therapy Association. 1990
Education Data Suivev: Final Report. 1991.
American Occupational Therapy Association. "Shortage of OTR's Estimated at 25 percent*. OT News.
November. 1989.
American Physical Therapy Association. Active Mem-
torehlp Preflk Stvidy. 1987.
American Dietetic Association. "Role Delineation for
Dietetic Practitioners: Empirical Results*. Joumai of
the American Dietetic Association 90181. August 1990.
SUverglelt. Ira. "Employment Settings of New Graduates". OTWeek. March 15. 1990.
Allied Health
�196
U.S. Department ofHealth andHuman Services. Health
Resources and Service Administration. Report to
Congress on the Studv of the Role of Allied Health
Personnel in Health C^re DcHvetv. Report of the
Institute of Medicine. National Academy of S-Mmrry
Washington. D . C . 1988.
U.S. Department ofHealth and Human Services. Health
Resources and Services Administration. "Rends in
Hospital Personnel: 1981-1988". American Hospital
Association Annual Surveys. DHHS Pub. No HRS-POD-90-4. U.S. Govenunent Printing Office. Washington. D . C , November 1990.
—
U.S. Department of Labor. Bureau of Labor Statistics.
Monthly T^bor Review U.S. Government Printing
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H e a l l h
Health Personnel -1991
�271
Appendix table 56. Estimated Numbers of Allied Health Personnel Employed
in the United States for Selected Years, 1970-1990
u
Occupation
1970
Dental hygienists
Dental assistants '
Dental laboratory t
^
Dietitians
Dietetic technicians
EMT-Paramedic
Medical records administrators
Medical records technicians
Medical laboratory workers
Occupational therapists
Orthotics and Prosthetics
Physical therapists
Radiologic service workers
Respiratory therapy workers
Speech pathologists/audiologists
3
Other alhed health '
1990
734,000
Alhed health personnel
w r h n
1980
a n g
1,245,000
1,797,000
40,000
112,000
31,000
17,000
2,000
35,000
10,000
42,000
135,000
6,000
1,000
30,000
87.000
30,000
19,000
54,000
156.000
53,000
32,000
7,000
70,000
13,000
60,000
249,000
25,000
2,000
50,000
116,000
56,000
50,000
81,000
201,000
70,000
67,000
16,000
98,000
18,000
69,000
297,000
34,000
3,000
71,000
122,000
75,000
85,000
135,000
262,000
490,000
1/
All numbers are rounded to tbe nearest thousand. Due torevisionsand independent estimations, some
numbers may differ from those that appear elsewhere.
21
Includes such categories as dietetic assistant, genetic assistant, operating room technician, ophthalmic
medical assistant, cytometric assistant and technician, pharmacy assistant, podiatric assistant occupational
and physical therapy assistants, physician assistant, vocational rehabilitation counselor, other
rehabilitaiion services, and other social and mental health services.
Source:
Health Resources and Services Administration, Bureau of Health Professions, Division of
Associated and Denial Health Professions.
Health Personnel-1991
Appendix Tables
�3
Appendix table 57. Enrollments and Graduates (Academic Year 1989-90) and Programs
by Occupational Type (Calendar Year 1990)
Enrollments Occupation
Total
Cytotechnologist
Diagnostic medical sonographer
Electroneurodiagnosdc technologist
Fiill-Time
260
635
176 ;
Profframs
Part-Time
Total
Total
247
597
172
13
38
4
210
338
63
46
43
14
3.349
183
10,807
2,089
168
8,751
1,260
15
2,056
1.817
104
4,516
72
37
185
5.136
4.216
920
1.444
215
Medical laboratory technician
(Certificate)
Medicalrecordadministrator
Medicalrecordtechnician
Medical technologist
Nuclear medicine technologist
1.532
2,292
4.150
5.734
U53
1.476
1.577
2,538
5,259
56
715
1,612
475
53
,848
671
1.165
3.024
611
41
55
108
420
107
Occupational therapist
Ophthalmic medical assistant
Perfusionist
Physician assistant
Radiation therapy technologist
7.986
129
345
3,017
962
7.322
110
338
2.897
949
664
19
7
120
13
2.424
72
206
1.120
542
69
10
26
48
104
18.693
7,912
6.032
79
95
2,512
18.061
6.983
5.451
64
95
2,325
632
929
581
15
-0
187
7.402
2,830
; 2.886
49
48
1,435
672
259
159
29
3
113
Emergency medical technician-Paramedic
Histologic technician/technologist
Medical assistant
Medical laboratory technician
(Associate Degree)
{
Radiographer
Respiratory therapist
Respiratory therapy technician
Specialist in blood bank technology
Surgeon's assistant
Surgical technologist
Source:
uoo
r
Allied Health Education Directory 1991, Nn t e t Edition, C m it e on Allied Health Education and Accreditation, American Medical
i ee nh
o mte
Association.
�ALLIED HEALTH SERVICES: AVOIDING CRISIS
INSTITUTE OF MEDICINE
NATIONAL ACADEMY OF SCIENCES
�INSrnUTE OF MEDICINE
CCMMTTIEE TO STUDY THE POLE OF ALLIED HEAUH PERSONNEL
WILLIAM RICHARDSON, Eti.D. Chairman*, Executive Vice President and Provost
Pennsylvania State University, University Park, PA.
J H E. AFFELDT, M D * Medical Advisor, Beverly Enterprises, Pasadena, CA.
ON
..,
STANLEY B J , M D * Professor and Chairman, Department of Radiology,
MM
..,
Hospital of the University of Pennsylvania, Riiladelphia, PA.
FIORENCE S. CKCMWELL, M A * Oonsultant in Program Develcpnent, and. Editor,
..,
Occupational Therapy in Health Care, Pasadena, CA.
E. HARVEY ESTES, M D * Director, Family Medicine Division, Department of
..,
Canraunity & Family Medicine, Duke university Medical school, Durham, NC.
G R L. FUZFMAN, Ph.D., President, Association of University Programs, in
AY
Health Administration, Arlington, VA.
POLLY FTTZ, M.A., Professor School of Allied Health Professions,
University of Connecticut, Storrs, CT.
ALGEANIA FREEMAN, Ri.D., Dean, School of Public and Allied Health, East
Tennessee State University, Johnson City, Tennessee.
SISTER ARLENE M G W N Vice President for Operations, Providence Hospital,
OOA,
Cincinnati, OH.
ROBERT E. PARTTIA, Ri.D., President, Montgcmery Ccrmunity College,
Rockville, MD.
EDYTHE H. SCHOENRICH, M.D., Director, Continuing Studies, Johns Hopkins School
of Public Health, Baltimore, MD.
C. E W R S H A T , Executive Director and Vice President for Medical Center,
DAD CWRZ
Hospital of the University of Pennsylvania, ftiiladelphia, PA.
•Member, Institute of Medicine
�FRANK SLOAN, Ph.D.*, Chairman, Department of Eooncmics, Director, Health
Policy Center, Vanderbilt Institute for Public Policy Studies,
Vanderbilt University, Nashville, TN.
PAUL M. STARNES, Assistant Superintendent, Hamilton Ccunty Department
of Education; Member, Tennessee House of Representatives,
Chatanooga, TN.
REED STRBJGHAM, D.D.S. Hi.D., Dean, School of Allied Health, Weber State
College, Ogden, Utah.
M R STRDBER, Ph.D., Professor of Eooncmics, School of Education, Stanford
YA
University, Stanford, CA.
RHEBA DE TORNYAY, R.N., Hi.D.*, Professor, School of Nursing, Director,
BWJ Clinical Nurse Scholars Program, University of Washington,
Seattle, W .
A
NANCY WATTS, Ri.D., Professor of Physical Therapy, M3i Institute of Health
Professions, Massachusetts General Hospital, Boston, M .
A
Studv Staff
KARL D. YQRDY, Director, Division of Health Care Services
MICHAEL L. MILLMAN, Stuiy Director
SUNNY G. YODER, Associate Director
JESSICATCWNSEND,Research Associate
MARYANNE P.KEENAN, Research Associate
CAROL C. MCKETTY, Research Associate
DELORES H. SUTICN, Secretary
OLIVE M. KIMBALL, Consultant
HAROLD GOLDSTEIN, Consultant
N O I BOOKER, Consultant
AM
RUIH B C N Consultant
RW,
NURTT ERGER, Consultant
WALLACE K. WATERFALL, Editor, Institute of Medicine
3
�This nyuit results fron the first large national study of the
enterprise known as allied health. I t identifies the major functions of
allied health practitioners, who have been relatively unrecognized ty
health policymakers. This situation often leaves the policymakers unaware
of the inpact of their decisions an allied health services.
Allied health personnel are the majority of the health care
workfaroe. They work in a l l types of care — primary, acute, tertiary,
and chrcnic — and in a l l health care settings, including physicians' and
dentists' offices, health maintenance organizations, laboratories,
freestanding facilities offering special services, ambulances, hone care,
and haspitals. The level of training of allied health personnel i s as
varied as the care they provide and the settings in which they work.
Allied haalth personnel include both highly educatgd persons and others
with only cn-the-job training. They wark with widely varying degrees of
autanany, dependence cn technology, and regulation.
But, there i s a paucity of information about them. There i s not
even consensus cn what the term "allied health" means. Cccpared with
nurses, physicians, and dentists, the allied health vrorkforce as a whole
has been very l i t t l e studied. Pronpted by a congressional mandate and
funded by the Health Resources and Services Administration of the U.S.
Department of Health and Human Services, this study by the Institute of
Medicine was intended to answer the following questions. First, what
roles do allied health workers perform and how will these roles f i t into a
changing health care delivery system over the next 15 years? Second, what
will be the future demand for sillied health personnel and how can public
and private policymakers ensure that the demand i s met? Third, should
these occupations be regulated and, i f so, how? And fourth, what sorts of
actions should educators take to prepare allied health practitioners for
the workplace of the future?
The cccmittee's reocmnendaticns are based cn what existing evidence
tells about some vital characteristics of the allied health labor market:
o the ccnpositicn of the labor force—namely the predcminanse of
technically ocnpetent w m n with a service orientation
oe
o highly regulated professions and work envircrments
o education prugrams unable to onrpete effectively with other
academic piugr HUC-. for 1 imiteri resources and sufficient numbers of students
4
�- 2o enplayers, undergoing sv^eeping changes in their financial
incentives, who must make hiring, ocnpensaticn, and vrorkforce allocation
decisions in the absence of good inform tien.
Throughout the study, a major challenge for the cenmittee has been
both to capture the diversity of allied health occupations and to devise
specific yet enccopassing IHTIIINHUlations for those who must make policy
decisiens affecting aTHpH health perscnnel. Toward this end, the
ocBmittee chose to focus cn 10 allied health fields. I t used the
following criteria in the selection of fields: that each of the 10 be
large and well-known; that collectively they span the spectrum of
autcnemy; and that collectively they vrork in a wide variety of health care
settings.
The fields selected are clinical laboratory technologists and
technicians, dental hygienists, dietitians, emergency medical personnel,
medical record administrators and technicians, occupaticnal therapists,
physical therapists, radiologic technologists and technicians, respiratory
therapists, and speech-language pathologists and audiologists.
The cccmittee hopes that this report i s only the beginning of a
pmi:ie«w that will clarify the place of a l l allied health occupations in
the health care delivery system.
Allied Health Perscnnel—Who are They and What Do They Do?
There have been many attenpts to define allied health and to
categorize the occupations that oould be oovertad by umbrella definitions,
lacking a satisfactory definition of allied health, efforts to class i fiy
occupations have been focused cn specific aspects of work and education
such as patient-oriented groups versus laboratory-oriented groups, or cn
the level of education needed. The results of these attenpts have not
been enthusiastically embraced by allied health practitioners. The
nnittee chose not to join in the search for a definition. The benefits
of making the term precise are less clear than the benefits of continued
evolution. The changing nature of health care TTWICOC OTHP practices and
practitioners obsolete while opening up opportunities for the fonnaticn of
new groups. I t i s more inportant that pragmatism ocntinue to prevail,
that old and new groups draw what benefits they can frcm belonging to
"allied health" than that a description of
characteristics define
the group.
Rather than define allied health, the ocmnittee chose to examine
policy-related characteristics of occupations that help explain how the
fields are differently affected by changes in the health care
envirenment. These characteristics include: a n n of autcnasy in the
mMt
%rorkplaoe, dependence cn technology, substitution of cne level and type of
perscnnel for another, flexibility in Ideation of enploynent, degree of
regulation, and inclusion in accreditaticn standards for facilities.
s
�- 3 Estimating Supply and Demand
In order to r^pond to the ccngressicnal charge "to identify
projected needs, availability and requirements of varicus types of health
care delivery systems for each type of allied health perscnnel", the
cannittee had to resolve i s ^ ^ of scope and approach. Given limited
funds and
the ocmnittee believed that its greatest ccntribution would
be to try to clarify the future outlook, which i s crucial to strategic
planning arei policy, rather than systematically assess the current
situation.
Paf^ T.-i-ni-i't-a't-irag
Hie ccmiiittee's ability to f u l f i l l its charge was severely hanpered
by lack of data, the result of a relatively low interest and investment of
public resources in learning about the allied health workforce, lhe
committee had to rely on data sources that include sane information about
allied health, however inocnplete and unreliable. The cannittee assessed
the existing data arxi nnprtnr4-t=ri hearings, site visits, and vrorkshops to
round out i t s own expertise and help to understand the farces that will
shape the future of allied health occupations. The cannittee could not
make quantitative predictions of personnel shortages and surpluses, both
bemus** of the " q ^ l uncertainties of occupational projections, and the
absence of the necessary data elements. I f esplcyers, higher education
planners, federal and state officials, and others had soundly-based
projections, decision making might be inproved.
The federal government in its role as mcnitor of the nation's
eooncmic activity has a responsibility to mcnitor the health workforce and
to inform participants in the health labor market and public policymakers
of trends and developnents. The work of the Bureau of Health Professions,
the Bureau of Taw-rr statistics, and the Center for Education Statistics i s
to be "rmmpnAari and should be built upcn. In order to inprove the data on
allied health fields, the ocmmitteeremnimndsthat the Secretarv of
Health and Human Services convene an interagency t-ack- force conposed of
representatives fron the Bureau of Tahnr st-atistics. the Center for
Education Statistics, and other agencies that collect relevant data on the
allied health workforce.
t-ack force shaild work tarard increasing
the diuumit and iaproving t « rp«i jty of data needed to inform public
h»
policv
decisicn-maker^,
h^^^
iranaqpre.
iminng.
prrx^vr+i™
students, and aead*^^ irert-jtuticns aboit the allied health onrnnaticns.
To help implement this reoannendaticn and others that follow
requiring federal action, the catrdtteereoanmendsthat the Department of
Health and Human Services •na-int-ain an organizational focal point on allied
froan-h porsonnel to inplement the grant utixjianfa iu,
^..lorf jn this
report, to coordjpai-o t-hereoaimendedwork of the interagency dato i-atsV
force, and to facilitate umnamicaticn between state legislative
oaimittees and the federal qoveuuifctnt.
�- 4Factors lhat Affect the Supply and Demand for Allied Health Perscnnel
A first step in understanding or projecting the future of allied
health perscnnel, either as a group or for individual fields, i s to
understand the ways in which certain farces operating in the envirenment
drive supply and demand. Early action in response to these forces can
forestall the need for more radical correctiens at a later date.
lhe current Employment situation
Available data do not enable a reliable estimate of whether the
supply of practiticners in the various allied health fields i s in
reasonable balance with demand. However, during the course of the study,
the cannittee was in contact with people who observe various portions of
the labor market for allied health practitioners. Ihese educators and
enplcyers expressed increasing concern about the availability of students
and practiticners. Educators generally report that their graduates find
jobs easily. Qiplcyers ndpuit increasing difficulties in filling
vacancies. Ihere are, of course, variatiens among fields and localities,
lhe most frequent reports of shortage heard ty the cannittee concerned
physical therapists. For other fields there were reports of less severe
shortages, or of hiring difficulties related to local ccnditicns, changes
in licensure, or a particular aiployer's problems, lhe volatility of the
labor market was illustrated: at the beginning of the study some
educators were conoemed about an oversupply of clinical laboratory
perscnnel; 18 months later the concern centered cn a growing difficulty
in hiring trained clinical laboratory perscnnel.
I t i s clear that seme changes in the health care system are causing
shifts in enployment patterns. Prospective payment and other efforts to
control hospital utilization caused initial reductions in hospital
enployment for sane allied health fields. For other fields the rate of
increase in hospital enployment slewed, and s t i l l others showed a
substantial increase. The growth of a l l sorts of out-of-hospital care has
accelerated, creating sane new sites for enployment of allied health
perscnnel. Whether in the leng run these translate into substantial
numbers of additional jobs or merely a shift in the location of enployment
i s an inportant question not only for projecting demand for allied health
personnel, but also because there are inplications for the way personnel
are educated to practice in new settings. Mareover allied health
practitioners working in these new settings also raise jfggnoc for
regulators concerned with quality and for traditicnal enplcyers who must
now cenpete for personnel with enplcyers who can scmetimes offer more
attractive salaries and working ccnditicns.
lhe cccmittee used the best available data to make assessments of
how the forces that drive supply and demand for allied health perscnnel
will affect allied health labor markets, lhe intention i s to alert
decision-makers to the kinds and magnitudes of market adjustnents that
they should expect and encourage in order to sustain a long-term balance
between supply and demand for allied health perscnnel.
7
�- 5I t i s the nature of markets to adjust eventually to change.
Projected infcalances in supply and dauand do not mean that shortage or
surplus will occur. Rather, they signal that enplcyers and potential
enployees must, and prctaably will, make adjustments. Only rarely do
markets not accccnodate changes in supply and demand. But there are
inherent time lags and inefficiencies in the process that can be lessened
by public and private interventions.
Ihe Future Qiployment Situation
Barring major eocncmic or health care financing contractions,
growth in the number of jobs for allied health vrorkers will substantially
exceed the ration's average rate of growth for a l l jobs. Unless sane
existing trends are moderated, the flow of practitioners into the
workforce through graduation frcm education programs will be, at best,
stable.
For T * * fields, such as physical therapy, radiologic technology,
mpriical record services, and occupaticnal therapy, we foresee a need for
decisicn makers to inprove the working of the market so that severe
imbalances in supply and demand may be prevented. Employers are already
ccnoemed about difficulties in hiring in some of these fields, and there
are signs that health care providers are beginning to search for ways of
aoocDmodating new realities. Because some of the aacamnodatians are
expensive and difficult to acocnplish, the cccmittee i s conoemed that
inacticn may cause crises that could be avoided—health care services
could be disrupted because providers of care are not availahle.
For sane other fields, such as clinical laboratory technology and
dental hygiene, there are factors that could cause instability in both
supply and demand. For these fields the market i s more likely to make the
needed adjustments and serious disruptions are less likely to occur.
However, in both of these fields there are unresolved issues ccnceming
the level of personnel that will be allcwed to perform certain jobs. The
way these issues are resolved could determine whether major imbalances
will occur.
Supply and demand for speech-language pathologists, audiologists,
respiratory therapists, and dietitians are expected to be sufficiently
well balanced for the labor market to make anooth adjustments. Ihe kinds
of incremental adjustments that make careers attractive and the ways in
which perscnnel are deployed appear likely to maintain a state of
equilibrium over time. Nevertheless, for these and other allied health
occupations, changes in many factors oould cause disequilibrium, ihese
factors include: health care financing policies, technology change,
decisiens about education piugiaim and regulatory policies. Those
concerned with respiratory therapy, for example, most closely monitor an
educaticnal capacity that has proved volatile, as well as changes in hone
nate TTPTTT^TTT^I-IIIM-IIpolicy.
�- 6Our ccrdusicns about the future outlook refer to the long i g - and
-im
they are national in scope. For a l l fields there are likely to be periods
of greater and lesser imbalance between now and the year 2000, as well as
local variation. The abjective of policy i s to make less painful and
costly the prrx-^g of adjustment. A decline in quality of care,
interruption or reductions of service, and curtailment of investment in
new technologies and organizaticnal farms (such as heme or outpatient
care) that might inprove the efficiency of health care delivery are a l l
possible byproducts of perscnnel shortages. The decisicn to intervene in
the labor market i s made through the political paxioess and reflects
society's willingness—or lack of willingness—to tolerate painful
dislocations. In many industries such dislocations are viewed as normal
and acceptable. Public policy actions have demonstrated that health care
is viewed differently. The cccmittee investigated how educators,
enplcyers, regulators, and government can facilitate anooth working of the
market.
Education
The function of the education sector in determining the size and
ocupositicn of the workforce i s clear. Unless educators, in league with
enplcyers and professional associations, are successful at fostering an
interest in allied health careers among qualified prospective stixlents,
both the putjr^mn and the allied health warkforce will weaken.
Demographic studies show that the Uhited States pcpulaticn 18 to 23
years old has been declining sinoe the beginning of this t^r^ri^ and will
continue to decline through the mid 1990s. Shrinkage of the college age
papulation will make i t increasingly difficult for allied health prograns
to attract qualified applicants. In addition, other attractive
opportunities cenpete for that population's attention. This suggests that
greater attention will have to be paid to maintaining allied health's
share of the traditional pool of students, and that less traditional
sources of students (such as minorities, older persons, and career
changers) should be tapped.
Academic allied health piugidms must overccme the perception, and
to sane extent the real ity, that they are excessively costly and that
their faculty do not make a sufficient scholarly contribution to their
institutions. Modest but strategic actions by the federal government can
help jjiujtams deal with these problems and cenpete more effectively for
academia's 1 imiteri resources. The ocmnittee iwrninmrte federal actios
that would provide a signal to others who carry most of the responsibility
— states, education administrators, and enplcyers — that these prograns
must not be undervalued.
Problems of allied health educators can be analyzed in ^y-m of
recruitment of students, financing of programs, and the supply of
qualified faculty.
�- 7Faced with increased ocnpetition for students, education
institutions nust bp^TT** creative in their approaches to recruitment.
Alliances with organizations also interested in recruiting allied health
perscnnel nust be forged. The cenmittee therefore recennends:
mv-^-ion institutions in close collaboration with enplovers and
orofessioryl ac^-j^r™;
ornanize forrecruitmentof students,
gnirtom-g should be sought in les* i-r^^i nal arclicant pools —
minorities, "l^r ^^nts. career t F' - those alrpartv emnlnved in
h^lffl TYP - "en
fields where thev are iTTY^rrrrrrPseaTted, and
individual wjtn ^aiTdjcaiTipq candjtisjSj.
n
r
VITY
rc;
8
ff
One way to create access to a larger pool of students i s to allow
entry into education through mltiple routes.
Alternate pathways to entrv-level practice shculd be encouraged
when feag-ihig. <?tate higher education coordinating authorities and
legislative caimit^'^ ghmid insist that education institutions
facilitate actoility between conmumtv college and baccalaureate procrraiTts.
Recruitnent of minority students i s a particular concern for
several reasons — minorities represent a relatively untapped source of
manpower, their representation in the population as a whole i s increasing,
and minority professicnals are ncre likely to serve underserved
pcpulaticns.
There have been a number of attaipts to recruit and retain
minorities in health professions. The lessons fron successful models
suggest that interventions must occur early in a student's life and
continue through the academic career. The major source of support from
the federal government has cane fran the Health careers Opportunity
Ftogram.
The remittee reootmends:
Minorityrer-rmtmpntefforts nust begin before high school.
Academic institutions mast offer academic support services for retention
and seek to prorcte e^raf-irmai mnhilitv. To succeed in the long run,
these efforts nust be made integral to the mission of prh^-inn
The cannittee endorses the obriectives of th* Ttealth Careers
Opportunity Program fHaDP> and believes rh^i- fimriing levels v t ^ aiTna-i^tained at current levels.
Allied health yrujranh are vulnerable to closure because they
appear to lag behind other prugrams in contributing to the academic
standing and financial health of the institution. The cannittee ™ r p a
ai
number ofreoccmendatiensdirected to several aspects of this problem.
�- 8 -
Hie overall strategy i s to put allied health piugiams cn a more equal
footing with other academic programs.
In order to enhance the stability of allied health education.
national organizations such as frnPT-jcan Society of Allied Ttoan-h
pyoft^-inns should investigate itmrio-j« -in whjr^ arertomi^ iT^-j^T^-jons have
gy^o^ri^ in broadenjrn
fiTVTrn
^ ^ ^ j h cv^ j n ^ ^ i ^
faculty practice plans, extension cairses. and indnsmr relationships.
Those national organizaticng gHmin a-jgn hniri wjricshajs to help
institutions inclement the modeJf apH i-o rfiCTniral-P information.
1
a
e
T
W i l ripari^e alternative arproaches are develcxaed. the fprtor^]
government and other third-raTt-y payers should maintain current
reimbursement levels and mprhan-igms of support for clinical education.
Tbe cannittee found that in seme fields shortages were inhibiting
expansion of education capacity despite bUujy student and enplcyer
demand. More generally there i s a perception that faculty are beocming
dissapwDciateri fron c l i n i c a l practice to the detriment of students'
preparation for the workplace. This i s i n part due to the academic reward
system which does not value patient care highly. Attention to faculty
s k i l l s , however, should not be at the expense of progress in solidifying
the research underpinnings that guide everyday practice.
The federal government and states shaild fund faculty deweloment
grants in allied hAaH-h fjolds especially when faculty avaiiafr-i j
^
lack of c l j n i ^ l cvportise inhibit the prarhv^jon of entrv-level workers.
A cadre of researchers and a ^ * ^ " ^ loaders i s needed to advance
the s c i e n t i f i c base of ^U?«^ hgait^ j ^ r r f j r ^ . ^ *ooonplish this.
institutions with strong research oaimi-tanents should consider developing
programs that identify and nurture talented individnaig. The ocmmittee
iBmuiimprig ^ federal research feilrMship program to support these
activities.
Private foundations should support centers for allied health
<rt-,v^ c and policy. These universitv-based centers w i l l provide a
c r i t i c a l page nf researchers and resources to advance technology
assessment,
<~Tvioes research, andftimanp^Troes utilization.
0
;
1
Instituticns offering ^ U l ^ f*^ ^ aoaA^io
and encourage faculty c l i n i c a l oaipetenoe. q j n i ^ ^ practic
sustains this occpetence should be made a requirement and criterion for
SEanctiark
Health Care Instituticns
Health care enployers directly generate dsnand for a n igrf health
workers and indirectly affect supply by the ccnditicns of enployment that
they offer.
�- 9 Tte cccmittee reviewed the available literature to determine the
sorts of activities that enplcyers could undertake to enhance the supply
of allied health workers by making a carepr in an allied health field more
attractive to people choosing an occupation, and by increasing retention
rates. Few studies of allied health were found. Most relevant wark i s
fron nursing, where intermittent shortages have focused interest cn what
i t takes to reduce nurse turnover. The literature makes i t clear that
enplcyers are able to affect eritxanoe and exit rates. Even a small
increase in tenure has a significant inpact cn the size of the workforoe.
• h cannittee recannends:
Xe
Enplovers shc^ri gtryre to i n c r e ^
^ j p l v of allied h^alt^
practitioners bv attracting pe«Tl? int" allied health and prolonging thofr
attachment ^
fields. Sane ways include increa^-inq nmponsation.
and developing m3ch?"jqng fm- retention. BiPlovers also should look to
new labor pools that •iTv-inrte rren. minorities, career changers, and
i f i i t i 1 8 vH-tj hanrKrarp-iTiq mnditions.
ntvri*«
Despite the reluctance of enplcyers to raise pay in a
cost-contained environment, i f shortages occur cccpensatian will increase
as administrators are ccnpelled to try to attract new entrants into allied
health professions. This will make allied health perscnnel a more costly
resouroe.
The occmitbee found l i t t l e evidence of the strategic planning and
researdi that oould help enplcyers effectively use allied health
practitioners and at the same time preserve quality of care, vxarking
within regulatory constraints and avoiding the professional resistance.
Nowhere i s there a substantial body of research to inprove the
effectiveness of allied health practitioners' activities.
Available data indicate that in many allied health occupations
entry-level pay i s currently conpetitive with other cccparable
occupations, but allied health salaries over the l i f e of a career are so
<* I^II^CM^ that there i s no incentive to remain in the occupation.
•
Effective use of manpower will necessitate conpensaticn incentives to
increase tenure, and work organized in a way that uses the greater
experience of the more expensive members of the warkforce.
The cenmittee reoenmends:
Hgan->ira-npproviders a r ar^ministrators should seek innovative
w*
ways to char^oi HT^+OH allied
-npgruroes to activities of proven
benefit to consumers. Agencies such as the National cgntar for Health
Services P^=^^i and the Health Care FinapciTiq Mmirfistration should
sponsor research and technology assessment to ensure that allied health
services are both effective and organized efficiently. Associations of
/Jl
�- 10 orplovers. unions. or-nprHtinq agencies, and profes-i"nal aggociations.
should a^-igt- in riij^minating research firriingg and providing technical
3
assistarv** i n iTrplpmentatian.
Health care managers will not succeed i f they are alone in these
efforts. Ihe educators and professicnal associations, who provide the
basis for practitioners' goals and aspirations as well as technical
knowledge and skills, nust also participate. Educators, enplcyers, and
professional associaticns nust engage in a regular interchange and
experinipntati cn.
Chief executive offic*>^=,frimanresouroe Hi-npr*-nrs. and other
yy^^h r^j* *rhn-mSgtrators nust develop methods for effective irt-iiiya^-iwn
of the existing supply of allied health perscnnel. Such methods nust grow
out of experijgntatian with na/ ways of efficiently organizing the work
and theriif=rt-r7bnticnof labor among gV-iTj levels, always ensuring that
quality of care i s not ocnpranised.
Baployers and educators nust forge a relationship to ensure that
graduates are not frustrated hy unrealistic expectations about what their
work will entail and eoployers do not ignore the needs for career paths
and professional stinulation. To be successful this effort requires that
Qsplcyers ani educators try to understand each others oanoems,
constraints, and the pressures exerted by a changing evnircnment.
Hea-jth par*, managers and arademic administrators nust enoaoe in
ombUuctive exchanges to inprove the congruence of enployment and
education. These exchanges, which should take place at the state and
local levels, will be enhanced by the participation of educators who are
also leadorr: nf the professional associations.
To facilitate this interacticn, the cenmittee reocurainds that state
legislatures estahi j gh special bodies whose primary purpose would be to
aririnpgw state and irr^i issues in the education and employment of allied
health personnel.
Licensure, Certification, and Accreditation
The coomittee took a broad view of the charge fron Congress and
examined the full array of regulation of allied health personnel,
including state licensure of individuals and health facilities,
oertificaticn of individuals by private organizations, the inposition of
standards ty third-party payers, and voluntary accreditaticn of education
programs.
Collectively, these regulatory measures affect the size and
characteristics of the allied health workforce. They affect the
functioning of the labor market for allied health workers by defining who
may enter the various fields, by determining who has what degree of
control over health care services and dollars, and ty censtraining the
range of staffing options available to aplcyers. They provide identity
and legitimacy to newly emerging occupations and their meobers.
/4
�- 11 Occupational licensure i s of particular concern to the cenmittee on
several grounds. As the most restrictive type of regulation, i t grants
exclusive control over c-"** health services to cne type of vrorker. Hie
cenmittee crrr^rW* that licensure i s costly and cunberscme and that i t s
effectiveness in protecting the public i s far frcm demenstrated. lhe
efforts in a nunter of states to reform the regulatory process are
encouraging, particularly the evolution of "sunrise" criteria for
evaluating the need to regulate new occupations, which the cannittee
erxSarses. Increasing the participation of the public in the regulatory
prffyss also i s a positive development. The cannittee LH X imiHrris that
states should strengthen the accountability and broaden the public base of
their regulatory statutes and procedures. In the near term, the cannittee
sin/jests;
Licensiirr boards should draw at le*gt- hai f of their manbership fron
outside the licensed oocnparArm: members should be drawn fron the public
as well as a variety of a r ^ ^ nf expertise such as health administration,
econanics. consumer affairr;, o^^-c-im, and health services research.
nearibilitv in lioensur° ^ ^ n - ^ should be mairfrair^d to the
greatest extent possible without undue risk of harm to the public. This
mav mean, for instance, allowing multiple paths to licensure or
overlapping scopes of practice for some licensed occupations.
In l i ^ i t of concerns about the future availability of adequate
numbers of allied health personnel, and in light of the rapid changes in
health care delivery, licensure appears to be inconsistent with the
flexibility that will be needed, lhe cannittee believes that states
should try to find alternatives to licensure. Professicnal groups should
work toward sLmig title certification, devoting their efforts to
convincing the public and the industry of the credential's value, as
certified public accountants have dene in their sphere.
lhe ccnimitt-e** rmnmends statutory certification for fields in
which the state detp-r-m-ir^ there i s a need for regulation, because this
form of regulation offers most of the benefits of licensure but fewer of
its costs, MpHira-ne and other third-party pavers should accept state
title oertification as a prerequisite for reimbursement eligibility. Such
certification cgn and should be based cn examinations and other
eligibility criteria the states establish.
lhe cenmittee was ccnoemed that jurisdicticnal struggles among
health occupations over scopes of practice and over referral and
supervision requirements are omrttYTt-eri without a body of research
literature or the informed judgments of knowledgeable, disinterested
parties to guide those decisicps. Absent such information, there i s
considerable risk that decisions will be made cn purely political and
eccnomic grounds. I t was the oenmittee's view that the federal government
should take an active part in developing the necessary evidence for use by
the authorities responsible for these decisiens.
�- 12 The Bureau of Health Professi nrre fnr other future focal points for
allied h ^ l t h personnel in CHHS) should sponsor a body with manbers drawn
fron allj»H h^ifh. cither he*n-h punfessicns. and from tN» > * n h ^
*asocial scienoe research cecimnities to assess objectively the evidence
bearing on "turf" i s s * ^
body, in consultation with other experts
anH ifft-pppgl-orl p a T l - j e s .
s h o u l d C o n s i d e r •ieoiog o f
risk,
post,
qiwt-i^
ar^
access. It should draw upon gvai,Table scientific evidenoe and identi
topics on which researr^ ^ rwrM.
Long-term care
Hie canaittee chose to devote special attention to long-term care
for a number of reasons. Ihe aging of the population and the need for
long-term care for the elderly i s a major force in future demand for
allied health services. Despite broad concern about the needs of the
elderly there i s no certainty that the current financing systems enable
providers to satisfy those needs. Further, because long-term care
requires both therapeutic and social support services, i t affords an
opportunity to examine issues surrounding the interaction of allied health
practitioners with other professions such as nurses as well as with
workers having relatively minimal formal education — an inportant group
of workers cn which the ocmnittee wished to focus attention.
Allied health practitioners relate differently to their clients and
to other health care providers in each of the three long-term settings
studied — nursing hones, hone care, and rehabilitation facilities. In
nursing hemes, minimally trained nurse aides are often the primary
caretakers with the most frequent patient contact. Recent congressional
and Health Care Financing Administraticn's actions to increase aide
training i s a step in the right direction. But, in the future, aides will
require a higher level of training to link them more effectively to
nursing and allied health personnel in the delivery of hands-on care.
In recognition that the greatest amount of direct patient contact
and care in long-term care settings and urwrams is provided by personnel
at the aide level, i-ho fprte-rai gnvemment and other responsible
governmental arpneies should require education and trailing tn raigg tho
knowledge and skiiig "f these personnel. Demonstration projects should be
funded to encourage joint efforts by educators and enplovers in creating
career paths fnr aides.
Some types of organizations that provide long-term care, such as
heme health agencies and nursing homes, must coordinate a wide array of
services needed by fragile clients with multiple disorders. Mishandled,
this can result in fragmented care, scmetimes duplicative efforts, and
often less than optimal use of each service. Collaborative tpam work by
the care providers would inprove the quality of care ty helping team
members to better understand each other's roles, ensuring appropriate,
coordinated care, and might even reduce staff turnover by increasing the
involvement in the job of each team member.
/5
�- 13 -
Hie cenmittee, therefore, reoamiends that hpransp the problems
acenniatgrt wi+h chronic i l l r ^ g ^ pot fall within the b ^ r a - o =
dntTi«
^
single i " rliT s- administrators and care ooordirators in long-term carr*
settings should develop effecfiv mparts for ensuring that a j j ppr-cnrm^
involved in patien^ rem M » k closely together to meet patent npprie
-r
a
H
Cif
i
v
Mare generally, allied health workers in a l l long-term care
settings need spprial preparation to take care of patients with chrcnic
illness, to understand the psychological aspects of aging, and to confront,
disability, death, and dying. Iherefare, the c a m i t t ^ p o m o H i-v^
pnmne
a l l allied f^aH-h PriivTatjnn and training programs include substantive
content and practical clinical experience in the care of the chronica Hy
i l l and aged.
Oollaborative Action
Taken as a whole, the cccmittee's reocciDendaticns are designed not
merely to advance the role of allied health occupations, but also to
preserve the ability of the health care system to confront the problems of
the next decade. In drafting its reoccmendations the cccmittee was
cognizant that no one entity in the public or private sector now has the
power or responsibility to determine whether allied health education and
practice will adequately respond to the challenge of changing patterns of
illness and care requirements. Ultimately, oollaborative acticn will be
required. None of our m * imipndati.ms i s self-implementing. Each
requires a principal party to convince others to join in their efforts or
to accede to alterations in traditicnal ways of operating, whether in
educating students, delivering services or supporting professional
interests.
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K NO SIKPS ARK TAKKN to Ixilster llie future supply of personnel in
several allied health fields, heallh care institutions will he hampered in
meeting the public's demand for services. I hese steps will rec|iiire coordinated actions by educators and employers, encouraged by modest but
strategic federal, state, and private programs. Many of the recommendations in this and the following chapter are directed toward educators, employers, and the allied health professions themselves. Although the committee
believes its recommendations will be beneficial to those parties, il looks to
public intervention to stimulate and amplify their implementation.
1 his chapter is divided into three sections. The first deals with policies
to influence the decisions of persons choosing careers. The second discusses
the role of educational institutions in maintaining or expanding enrollments. I he third addresses concerns about the preparedness of the future
allied heallh work force.
T H E ALLIED HEALTH STUDENT APPLICANT POOL
For most fields the available trend data on allied health programs and
graduations do not signal an imminent crisis requiring dramatic public
intervention. Looking to the future, however, the committee is deeply
concerned that the weak infrastructure of allied health education may
compromise the system's ability to maintain enrollments, let alone increase
the supply of personnel in fields in which employment demand is high. A
key to the viability of allied health education is its capacity to maintain its
159
�160
ALLILI)
HEAUH
SLKVIUiS
share of qualified students from the traditional college-age applicant pool
while tapping into less traditional pools of students, pal ticularly minority
students.
For a number of years, allied health deans and program directors have
expressed concern about the declining number of applicants to their programs and the implications of this decline for the academic quality of the
student body. Reportedly, spaces in many programs are going unfilled,
and this lack of student interest is jeopardizing the survival of academic
programs. Comprehensive data collection concerning applicants to allied
heaith programs is not currently being done. However, CAHF.A annually
surveys program directors in several allied health fields about, whether
applications to their programs are increasing, decreasing, or remaining
stable. In its 1987 survey, program directors in 13 of 22 fields reported
decreases in the number of applicants (CAHF.A, 1988).
The clinical laboratory fields in particular were experiencing distress.
For example, almost two-thirds of the medical technology program directors reported decreases in applicants in 1987. Of the 116 programs lhat
voluntarily withdrew from CAHEA accreditation between 1983 and 1987,
36 attributed their decisions to a declining applicant pool.
Unpublished survey data from the American Society of Allied Health
Professions suggest that only physical therapy has a large applicant pool
to draw upon, with about five applicants per academic space. Other fields
such as dietetics, medical technology, radiologic technology, and medical
record administration average, only slightly more applicants than needed
lo fill their classes.
A recent (1987) survey of the College of Health Deans, an organization
composed of allied health administrative units in 20 universities wiihout
medical centers from 17 states, revealed that only 3 out of 17 respondents
reported that all of their professional classes were filled. Although clinical
laboratory programs were those most frequently cited as having excess
capacity, many other fields also reported unfilled classes.
Although the current level of applications worries academic administrators, they are even more concerned about lhe future because of the predicted decline in the college-age cohort of the population, an issue discussed
in Chapter 3. This decrease suggests that in the future there may be even
greater competition among schools for technically oriented students than
there is today. Information from annual surveys of college freshmen on
changing occupational preferences shows a slow but steady decline (from
3.3 percent to 1.1 percent) between 1977 and 1985 in women's interest in
careers in laboratory technology and dental hygiene, dietetics and home
economy (from 1.1 percent to 0.4 percent), and health technology (from
3.7 percent to 1.8 percent). Women's interest in the category headed "therapist" has remained relatively stable over the period; men have exhibited
^ d u a U , increase in.ere* « r U,e y e a , ( C o o ^ u i v . .nsuu.uona, « ,
- ^ I L S - ^ a,,,
Vexing (ACT, P r ^ a m .««
' J L ^ a l i , , (Table 5-1).
' t o , e , e a M l,eal,h . « .as
J ^ S
evidenced hy "ha. has occurred ,n .he , ry c.' ' ^ W
ry
^
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.
m o s l
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a d e ^ e /apply of apdirectors repor. thai they s . 1 I . ve mm
1
^
plicams and can linm enrollmem . .hose w ml, e B
f. no. unusual ,o fmd
ft^SJi
.herapy.Tfew of .he
acceptance rauos of 10 lo K In a idmon
vy
^
i s
equate the success of programs like: perlu«i >
^
^
TABLE 5-1
Majors
^
^
^
^
I
'
m
^
s
a r e
^
ACT Tes, Score Means for Students Specifying Academic
mac
Percentage
Change,
1986- 1987 1980-1987
13.2
15.5
18.2
16.6
18.0
15.4
15.9
19.8
13.5
15.4
18.6
17.5
18.8
15.9
16.3
20.4
13.3
15.0
18.2
17.5
18.5
15.8
15.9
20.1
0
-1.1
0
-0.8
1.0
1.4
-0.3
0.1
18.2
18.3
18.7
1.1
ATTComposite Test Sa>rcs_
.
*
Academic Major
Dental assisting
Dental hygiene
Medical technology
Occupational therapy
Physical therapy
Radiological technology
Nursing (RN)
Pharmacy
Overall college-bound
population
13.3
16.1
18.2
16.7
17.8
14.4
16-2
< "
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�l:A)ULAniJ^'\i- i i/i.x./
(respiratory therapy and critical care nursing, for example) and therefore
have had some ex|X)sui e to the new field. Employment oppoilunities abound,
and not all graduating students enter the clinical field because other attractive opportunities are often available. For example, manufacturers and
biomedical engineering laboratories hire some perfusionists; some enter
medical school and others choose teaching. Although perfusion is a highstress profession, it is also a relatively well-paid one. Fhe average salary for
a graduating student is $35,000, but highly qualified and experienced
perfusionists may earn close to $100,000. Although (hey are not known to
the general public, perfusionists are respected in the allied health world
for their success in garnering earnings and their relalive independence
(Brown, 1987).
Why do some programs fare better than others in attracting studeiils?
Some reasons come readily to mind. Undoubtedly, the positive economic
outlook for physical therapy—rising salaries, growing autonomy, and high
levels of demand for graduates—has affected student thinking. Also, in
comparison with such fields as clinical laboratory technology, physical therapy has greater public visibility and more patient contact.
There may be lessons to be learned from schools of social work, which
have succeeded in increasing their applicant pool from 2 applicants per
opening in 1983 to 3.5 applicants per opening today. Social work is considered to be closely related to (if not directly under the umbrella of) allied
health. Deans of schools of social work attribute the revitali/ation of interest
in social work careers to a wide variety of social and economic factors,
including the following:
• optimism about the status of social welfare programs in the postReagan era;
• a surge (although not as dramatic as during the 1960s) in the sense
of social commitment among students;
• occupational outlook projections of higher-than-average growth in demand;
• growth of independent practices and third-party payment;
• adoption by some schools of "business-like" approaches to marketing
and recruiting students; and
• salaries that, while not high initially, averaged about $27,800 in 19861987 (Health Professions Report, 1988).
Visibility and comparatively high pay are elements that contribute to the
attractiveness of a field, and these in turn contribute to the success of schools
in obtaining high application rates. Some fields that are viewed by the allied
health community as being attractive and offering well-paying careers nonetheless do poorly in attracting students because they lack visibility. For
example, occupational therapy shares many of the attributes of physical
• s r ^ nso^tT ^ ^ ^ i
EST, r
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Student Recruitment
^ ^ V ^ T Z ^
of , e c h „ u e ,ha, Khcch have « » . « . » c .
iq
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,„ emnl,a*c the continuous and progressive aspects of
X Z Z & Z possthle primarii, for persons who are reia-
�A l . U t D H E A L T H SERVICES
lively free to choose any career and for whom both psychological and
economy resources are ava.lable. Such criteria do not necessarily fit women
and minorities (Fit/gerald and Crites, 1980)
The impact of several variables (including parental socioeconomic status
fShSJ, academtc achievement, and sex) on both selection and persistence
in career choice has been investigated in an attempt to determine who is
being recruited mto professions in general. These variables were used to
analyze responses from the U.S. Department olT-duca.ion's 1972 National
I,>ngaudina Study and recent follow-up surveys. Results showed that child.en of high-SLS parents were four times more likely than children of
low-SES parents to engage in professional study ai the baccalaureate level
and s,x t.mes more Iikely to participate in or complete professional trainin,,
at the graduate level. The SES level of patents did not have as much effea
on the aspirations of children, however; children of high-SES families were
1
1
h r i r
IromTw
T ^
^ *r ^ '
™™
«
^ m p ^
suiiiihl «)chl
'
™ - r have concluded that the idea of substantul social and economic mobility in the United States has been ex™
geratec. and ,s d.fficul, to achieve. Only 2 percent of young p ^
S"
ow-SES homes were ,n graduate-level professional programs 7 years after
S
R
S
ot:«dT
t e
a ge f e t l e n , j s i i , d e m a i d
!:
^
s
p,ograms to stim,i];,,e op,x,ru,mties in the
^rs™
:::;:™::,r:;x:r' -
In general, lhe career choice literature does not provide detailed cuid-
5 Ya
l
K
P
a r e
""^^
o n |
*J
T T u ^P™***
y economic animals and that work is
chMen only for the livelihood it offers are loo simplistic. Work also proJide
a means for meeung the needs of social interaction, dignity, sel f e teem
I ' t ^ r
l'
^
^
W * * * * * * * g-lfficalion
•
• Personal, educational, occu,«,iional, or career maturation comprises
r
]
3
0 f
m
g processesthatbegin inea, ,yd
i,
d
z&r
4^^zz^:
- —«
i n tinie bi,t in
s
-
• Career information must include not only objective factors such as
earning possibil.t.es, training requirements, and nun bers of po^t o, av,
able but the social and psychological aspects of careers as w e T
• Career choice is frequently a compromise between the attractiveness
o d of aini,,g and hec !is
a
&r£^£r "
'"
In sum, the literature on career choice is suggestive rather than nre-nptive for recruitment tactics. Long-range efforts must take into account
EDUCATIONAL f O L l C I o i i u u - /.» /.».
>
the need to make individuals aware of careers at an early stage. I f women
continue to predominate in many of the allied health fields, we must learn
more about the dynamics of their career choice behavior.
Successful student recruitment efforts generally depend on positive market signals emanating from the world of work. In the next chapter lhe
committee discusses actions that employers must take to improve the circtimslances of allied health personnel in work settings in which the perceptions of unsatisfactory careers accurately reflect reality. However, to the
extent that potential students incorrectly believe that a career is unsatisfactory, the problem may require improved communication. Local consortia of professional association members, employer representatives, and
educators should be formed to devise recruitment strategies based on community needs, characteristics, and resources. These consortia should target
nonlraditional audiences, tailoring the message and method of communication to each. A marketing plan geared to attracting newly unemployed
workers from a local industry, for example, should not be the same as one
that seeks to attract displaced homemakers or handicapped high school
students.
The demand for technically oriented people is growing in many sectors
of the economy. One study predicts that
The jobs that will be created between 1987 and 2000 will be substantially different
from those in existence today. A number of jobs in the least-skilled job classes will
disappear, while high-skilled professions will grow rapidly. Overall tbe skill mix of
the economy will be moving rapidly upscale, with most new jobs demanding more
education and higher levels of language, math ancl reasoning skills. (Hudson Institute, 1987)
More specifically, more than half of the new jobs created between 1984
and the year 2000 will need some high school education. Nearly a third
will require a college degree; today, only 22 percent of occupations require
a college degree (Hudson Institute, 1987). The health care industry is not
the only industry that is beginning to understand that one of the challenges
of the future will be to position themselves favorably in the competition
for the supply of educated, technically able workers. For some allied health
fields, there are already indications that potential practitioners are being
lost to other professions. It is clear that educators, employers, and the
professional associations must act if they want to maintain or increase their
share of the work force. The process of change is necessarily interactive.
If employers succeed in making allied health employment more attractive,
educational institutions will experience increases in the size and quality of
the applicant pool. Yet, circularly, the extent to which employers are able
to alter the conditions of employment depends in part on the education
that workers have received.
�l
o
w
ALLIED HEALTH
SERVICES
The committee recommends that educational institutions, in close collaboration with employers and professional associations, organize for the
recruitment of students. They should seek persons from less traditional
applicant pools—minorities, older students, career changers, those already employed in health care, men (for fields in which they are underrepresented), and individuals with handicapping conditions.
Minorities
Two major societal problems underlie concerns about minority panicipation in allied health careers, leading the committee to devote special
attention to this issue.
First, as several recent public policy documents have stated, minority
populations in the United Slates have comparatively poor health statuses
ami use fewer health care resources relalive lo their needs (U.S. Department
of Health and Human Services, 1985). Although a causal relationship between the supply of minority practitioners and imptoved minority heallh
care and health status is difficult to validate, minority health care workers
are more Iikely to work in geographic areas and at delivery sites that serve
minority and other disadvantaged patients. Officials interviewed at three
mner-city hospitals, including two public hospitals, said that minorities are
at least 50 percent of their tou.l allied health work force. Moreover dala
extracted from facility records show that this pattern is relatively uniform
across such different fields as clinical laboratory technology, physical and
occupational therapy, dietetics, and medical records (Booker, 1987).
Second, there is a lack of parity throughout American society between
whites and nonwh.tes in professional positions. To the extent that the allied
health fields can provide improved career opportunities for minorities a
doub e benefit will occur: education programs will be better able to maintain
enrollments, and personnel shortages may be alleviated in underserved
geographic areas and institutions that serve poor minority populations
Fo supplement a review of the literature on the representation of minorities in allied health fields, the committee conducted extensive interviews
with deans and faculty of 10 schools active in the National Society for Allied
Health (an organization committed to increasing the participation of black
and other disadvantaged minorities in allied health practice, education and
administration). Other schools were added in an attempt to broaden the
information base. A school known to have a predominantly Hispanic student body and structured activities to recruit Hispanics to allied health
programs was selected, as was a school in an area with a large American
Indian population. Finally, a nonminority school in the South was added
because it boasts the largest number of allied health programs on a single
campus and has been actively involved in minority allied health recruitment
EDUCATIONAL
I'ULIC) z uui..
and retention efforts for some time (Booker, 1987). Pertinent information
f rom these interviews will be ref erred to in our discussion of minorities in
allied health education.
Fable 5-2 presents estimates of racial and ethnic characteristics of allied
health personnel based on the results of an analysis of ihe 1980 census.
I he daia show that minority personnel are underrepresented, relative to
their representation in the U.S. labor force, in the 10 allied health fields
studied by lhe committee and particularly in the fields requiring higher
education.
CAHF.A reports that over tbe entire range o f t h e fields it accredits the
racial mix of students enrolled during 1980-1987 generally mirrored the
racial mix of the U.S. population. Blacks represented 11 percent of total
enrollments, Hispanics, 6 percent, and American Indians, about 2 percent.
What these data f ail to reveal is lhat minorities are overrepresented in fields
requiring less education and underrepresented in fields requiring more
education. The extent to which minorities have a higher departure rale
from programs and careers is not known. Several professional associations
in Fields requiring baccalaureate and advanced degrees have commented
on the need for greater efforts to increase the number of minority students.
For example, the 1984 Study Commission o f t h e American Dietetics Association noted:
While no effort has been made in the past to restrict other racial groups, or males,
bom tbe profession, little has been done to make the profession more attractive
to them, nor has any strong effort been made to recruit them. Tfie 1984 Study
Commission believes such an effort is overdue.
TABLE 5-2 Distribution of Personnel (Percentage) in Selected Allied
Health Occupations by Race or Ethnic Origin, 1980
Minority
Occupation
Laboratory technician
Dental hygienist
Dietitian
Medical record technician
Occupational therapist
Physical therapist
Radiologic technician
Respiratory therapist
Speech and hearing therapist
White (not o f
Spanish origin)
79.5
95.4
84.(i
84.4
94.7
93.4
8().2
82.1
92.9
Black
While
(Spanish o r i g i n )
Other
Minority"
1)1
1.6
6.7
9.5
2.1
3.3
7.7
10.0
4.3
3.3
1.6
1.9
2.2
0.9
l.l
3.7
4.9
1.5
6.2
1.3
8.0
3.9
2.4
2.0
2.4
3.1
1.3
"These figures include American Indians, Japanese, Chinese, and other Asians or Pacific
Islanders.
SOURCE: Health Resources and Services Administration (1984).
�ICQ
168
ALLIED HEALTH SERVICES
Past Efforts to Increase Minority Participation
The Federal Government
The federal government first initiated programs to encourage "culturally
or economically disadvantaged individuals" to enter allied health as part
of the 1970 health manpower legislation (P.L. 91-519). This statute was
extended in 1973 by the Comprehensive Health Manpower Act (P.L. 92157) and the Health Programs Extension Act (P.L. 93-45) and in 197('> by
the Health Professions Educational Assistance Act (P.L. 94-484). Litter, an
administrative decision was made to provide support for projects that emphasized the recruitment and retention of minorities as well as the disadvantaged (Carpenter, 1982).
Between fiscal years 1972 and 1977 approximately $20 million of a total
of nearly $191 million of giants awarded for allied health were allocated
for programs targeting minority and disadvantaged populations. Between
1978 and 1981, under P.L. 94-484, a larger share of the total but a smaller
amount was awarded for project activities to assist disadvantaged allied
heallh students (Carpenter, 1982).
By fiscal year 1982 the only federal funding of any magnitude that was
available for minority recruitment and retention in allied health training
was the Health Careers Opportunity Program (HCOP). HCOP has five
objectives: (1) recruitment, (2) preliminary education (noncredit), (3) facilitation of entry, (4) retention, and (5) information dissemination. Examples of HCOP activities include career fairs; faculty counseling"; tutoring;
summer enrichment programs to enhance mathematics, science, and communication skills; and linkage arrangements among undergraduate schools
such as historically black colleges and universities (HBCUs), community
colleges, and high schools.
Between fiscal years 1982 and 1987 the number of allied health grants
under HCOP increased steadily, as did the funds that were awarded. Of
the $60 million or more awarded since fiscal year 1985, $5.37 million has
gone to allied health programs. The proportion awarded each year to allied
health programs rose from 5 percent to nearly 10 percent during this 3year period (W. Holland, Division of Disadvantaged Assistance, Health
Resources and Services Administration, personal communication, 1987).
The Area Health Education Centers (AHEC) Program assists health
professions schools in improving the distribution, supply, quality, utilization, and efficiency of health care personnel in the health care service
delivery system by encouraging the regionalization of professional education. The program has no legislative mandate to recruit and retain minorities, but it has explicitly encouraged such activities. In fiscal year 1987,
AHECs in Arizona, New Mexico, Texas, California, Oklahoma, and at three
black medical schools—Drew (Los Angeles), Meharry (Nashville), and
,„„me,u co .rainme l>"> ?»«»»*•.<"J ' ^ ™
popuUions. I V AHKC ' ^ , ^ 3
l '
and ,ewa no, oUainable
S
t
e
s
S
1987).
Thealthpro.essions
e d u c a t . n ^ ^ t ^ ^ ^
have been devoted to mcreasing . e s ^
^
dentists, but a lew stales suppott , t a uve*lo^
^
- i n i n g - For example, Gonncc ,cu h ^ d he H ^
^
gram, which exposes high st.liool M_u
,, j
. dtgtble
; ( l l i e d
G
i a
h e a U h
Are
Lnomically ^ » » « ^ ^ $ ^ < y
Cant IVogn.m (Manfor a small grant P' ^ ^ ' / ^ . , ^ ^
L e d an action plan to improve
dex, Inc., 1987). New York St.ue has
™ ^
minority access to the licensed ^ ^ ^ ' ^ p y , J f occupational
1
therapy), the core of which is a
development and teachmg m
f ^ ^
12. i„ addition, the state offers
fi"^^
wiUingto w o r k i n g
Department, Bureau ot Highei j m 1
Allied health is rarely specifically »
funding. Several invest,^
" ^ " J
spent for allied heallh education ^J"^
^
.
m
-
Z
^
^
^
—
,
(
N
- .
7 through
Hied health students
State Education
a c l e s
0
a
e
w Y o r k
,
^
,
t o
^
„
,
,
, i n for targeted
the amount
not distinguished
,3
health pvo-
e R i s l a
;
f
( )
s c e r t a i n
a r e
a l l i e d
i and retention
through
a line item in the state budget.
Private Foundations
p^ate organizations .so ^
Jn —
Lunhealth care careers.! he Josiah M. cy Jn, and Ro
dations have been quite active , the see ^ . ^ ^
indude allied
Johnson ^
^
^
^
^
^
allied health professions
health professions Macy has P » " ^
. , involvement
training, but its primary rocus,
more « a
^
^
^
minority health professions education
s«.l p y
^
W ( ) ( ) d
I l o t
S
S
2
0
s ()
M a c y
i n
Bleich [1986, 1987].)
�170
ALLIED HEALTH SEIiVICES
The basic concept of Macy's high scliool model is to use foundation
funds to supplement tax levy suppoit for participating schools. Strengthening curriculum and premedical advising early in a high school student's
education is the cenlerpiece of this program. Linkages between colleges
and universities and the high schools are common and serve as vehicles
lot faculty development, student exposure to careers, and academic enhancement.
For example, five high schools located in the three poorest (50 percent
of all families live below the federal poverty level) counties in rural Alabama
have completed a 4-year cycle in the Macy project. Macy reported the
following results.
• O f t h e originally selected 114 students, 79 percent were retained in
the honors program.
• All of tlie honors students scheduled to graduate did so and are going
to college; all but two anticipate attending a 4-year school.
• Thirty-three of the 88 graduates specified that they would pursue a
heallh career; 3 specifically cited physical therapy.
• Fhe Macy graduates took the mathematics placement exam given to
all University of Alabama incoming freshmen. Of the group, 88 percent
placed into calculus or precalculus—55 percent in calculus and 33 petcent
in precalculus. Macy notes that less than 10 percent of all Alabama freshmen
did as well (Bleich, 1986).
The program in these schools, which is called the Biomedical Sciences
Preparation (BioPrep) Program and operates in grades 9 through 12, is
conducted in conjunction with the University of Alabama School of Community and Allied Health, a school committed to increasing the number
of health professionals practicing in rural Alabama. Many of the Macy
graduates (57 of 88) were awarded tuition scholarships by the university.
Prior to the BioPrep program, school systems in the three counties (two
of them predominantly black with a median of 8.5 completed school years)
were unable to identify gifted and talented youth. Initially, there were
concerns about the schools' ability to attract suf ficient numbers of students
for the program; those fears have proved to be unfounded. Macy schools
were able to attract more than 100 young people to their rigorous academic
programs that emphasized science, mathematics, and language skills. In
addition, new classes are being enrolled in several schools, and "in each
setting there is growing interest and demand for a more rigorous curriculum" (Bleich, 1986, 1987).
Extensive in-service training has taken place, and curriculum development has been a collaborative activity among high school teachers, BioPrep
staff, and selected university faculty. Tutorials, enhanced science laboratories, and independent study have been offered at the schools; bimonthly
EDUCATIONAL POLICYS ROLE IN INFLUENCING SUPPLY
171
Saturday sessions and 6-week summer programs have been held at the
University of Alabama.
„„ipnis h ive enThe M .cv Foundation reports thai more than 1,200 students have en
c
X r i ^
S«'"n ce ,„ produce
s
S
y
« changes d,a, can l,e msuumon.
alized for long-lasting benefit.
Lessons That Have Been Learned
More than 20 years of experience in attempting u,
of minority allied health professionals suggest four areas that should
targeted for action:
. te tdemic preparation, especially in the sciences and mathematics;
. ^ / . r f allied health careers and the promotion ot mtnorities,
• financing of institutions and students; and
. linkages and affiliations in training and employment.
Despite efforts of the federa. government and individual
i
—
^
stakeholders can lead and contribute to greater success.
Aaidemic Preparation
Astin (1985) notes that minority underrepresentation in engine^ing
' " H C O ^ n t e s ' w i c T y ' L v e fKused on s , r e n h e „ , n .he stiHs of
Sl
B
�172
ALLIED HEALTH SERVICES
interventions. Although there is partial evidence (La Jolla Management
Corporation, 1984) that such interventions can work, the conventional
wisdom is that the emphasis on mathematics and science should hegin as
early as possible, starting at or even beldrc junior high school (Bisconti,
1980; National Commission on Allied Health l-xlucation, 1980; Hack, 1982;
La Jolla, 1984; The Circle, Inc., 1987; Mingle, 1987). Perhaps allied heallh
schools could gain more in the long run by helping to create alliances with
others in the community to attack the root causes of poor academic preparedness.
Allied health schools generally draw theit students Iiom known "feeder"
sources. Strengthening academic preparation at the secondary school level
and in other major feeder schools (e.g., community colleges) can contiibute
to lasting improvements in the (]uality of their applicant pools; it can also
influence curriculum improvement at feeder schools and bring greater
visibility to allied health career opportunities. At the same time, early academic and career counseling, a compounding factor (Committee/staff interviews, 1987; La Jolla, 1984; The Circle, Inc., 198(5), can be enhanced.
The Josiah Macy, Jr., Foundation provides an excellent example of what
can be accomplished if students are introduced to intense academic skills
improvement programs early. Macy's success also offers an example of
what can be accomplished by approaching problems from a broad perspective. The foundation incorporated a wide variety of resources and
addressed areas other than the student's grade point average. It also concentrated on raising school administrators' and teachers' expectations of
students, educating parents, acting as a liaison to establish collaborations
between colleges and public secondary schools, and raising students' selfesteem.
Knowledge About and tlie Promotion of Allied Health Professions
Information plays a role both in attracting minority students to careers
and in keeping them through training. Informing minorities about the
wide range of allied health occupations and promoting these fields as career
options are important steps in attracting minoi ity students to these professions.
Educators believe that better information about an occupation's training
and practice is crucial to the relatively high attrition rate of minority students in the First year of professional training. Such information is not
easily acquired, however. Allied health professions are not widely mentioned in the media, nor are the contributions of allied health occupations
to health care delivery explained.
Those interviewed for the study reported that information dissemination
through career days, the distribution of brochures, and active recruitment
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
173
is most effective when coupled with formal and informal linkages with
feeder high schools and colleges. One school that recently began recruiting
through churches reported that they were a rich and largely untapped
source of minority allied heallh applicants (Booker, 1987).
Research data and the experiences of recruiters suggest that the f ollowing
factors should be taken into account in shaping effective information dissemination and promotion campaigns ( Fhe Circle, Inc., 1987; Mingle,
1987):
• Minority allied health students are likely to be older than liberal arts
students; they are also more likely to have children.
• Students who demonstrate potential in high school or community
colleges may make up a greater percentage of the applicant pool than high
achievers who are already being heavily recruited for medicine, engineering, and other professions.
• Community colleges can become a good source from which to draw
students interested in earning a bachelor's degree, especially if linkage
arrangements that incorporate approaches to sharpening critical skills and
increasing students' awareness of career options are implemented.
• Persons who are disenchanted with their current occupations in other
fields may be seeking an opportunity to pursue a new, more challenging
and rewarding career.
Financing for Institutions and Students
Deficiencies in academic preparation are fairly widespread among minority allied health students, and deans of allied health schools expect this
shortcoming to continue in the near term. They believe that financial
support will continue to be needed for activities that help struggling students remain in school. These activities include prematriculation summer
programs, faculty and peer tutoring and counseling, computer-aided learning assistance or instruction, and curriculum improvement/faculty development in feeder schools.
Deans of allied health schools have concluded that external support, such
as that provided by FICOP, is essential to underwrite some of these institutional expenses ( Fhe Circle, Inc., 1987). In general, intensive minority
recruitment and retention activities are supported, at least in part and
frequently at a substantial level, by external funds. HCOP has been predominant here for all activities except curriculum improvement in allied
health training programs. A 1984 assessment of HCOP-supported preparatory activities (i.e., preliminary education, entry facilitation, and reten-
�174
ALLIED HEALTH SERVICES
non) concluded: "Since by far the largest expenditures for HCOP are for
preparatory actm.ies, it is essential that HRSA [Health Resources and
Servtces Adnnn.strafonJ and d.e grantees locus special attention on o
vtdtng those preparatory activity services that produce the greatest benefit
i a t l , " ^ '
^
"
^
Mana^nent 0 ™ t
6
0 1
P n , 8 n , m
(
U
h
Since 1978 funding for allied health uncle, HCOP has increased ,s •,
pmportK,,, of the total HCOP investment, bu, total f unds fo, the p ^ m m
as a whole have d.tntmshed and authorized purposes have be •„ more
narrowly def.ned. For example, there ate currently no federa. p, ,g, n !
that support mmonty allied health faculty development or curriculum improvement m m.nority schools or in nonminority schools that view curriculum changes as one way to recruit and retain more minorities
I he preeminent Minority Access to Research Careers (MARC) and Mi
"onty Biomedical Research Support (MBRS) programs/the oldest of die
(
a
d
n
S S I i S r ^
— ^ ^ National
^
tutes ot Health (NIH), support these kinds of activities, as do other similar
programs. Such programs have been credited with substantial » m r i b T f a n
•n increasing research research training, and the number of r t
X
in mstituuons that train large numbers of mine, ities. Included in this d u ^
are s.gntftcant numbers of traditionally and predominantly minority
^
(Garrison and Brown, 1985; Gonzales, 1987)
onty schools
L
A
W i t l 1
l a c k
, !""?
"
orinMitutional support, insufficient student financial
aid is also seen as a deterrent both to minority student recruitment and
retenuon. Allied health deans cited .ack of funds as a n ^
".son" r
s udent attnfon Many minority al.ied health students are olde a, d h
h.ldren; many of them find that school schedules generally do not , erZ
iH
S U C h
C i r c u m s t a n C e S
aor ^ n T " " " ^ ^ " ^ ^
' "nandal aid is a
S
factor in heir persistence m working toward a degree. Bisconti (1981)
, n
a l l i e d
h e a l t h
m a
0 r
i s
th m a N ' ,
^
'
-"ore expense
dwn. a libera arts degree." Tuition costs may not be higher, but there n ay
be add. nal costs for clinical education and materials^- equipment F tM
Ur
0
<
( b 0 t h
p r e p r o f e S s i o n a l
a
n
d
i T ^ l o n g e r
^ " ^
Professional)
Although states are investing in educational support for minority health
professionals the s.ze of these investments varies widely, and most snte
a,d is targeted toward medicine and dentistry. The committees ^ r iew
T t
«
^ financial W
medtal and dental professionals (e.g., the National *
nd d ' T
^
^ ^ Corps
medical
Health Service n of
1 t h a t
1 0
p r O V i d e
t 0
m
0
r
e
s h i f t i n
u
d
t h e
d
can forgiveness, AHEC) offer incentives for minority professionals to Z k
T
h
e
S
e
1 , Z T u ^
for alliedf health f practitioners.
S t r a t e
&
i e s
t h a t
be equally effective
cuccuve
y
EDUCATIONAL I'OI.ICYS ROLE IN INI LUENCING SUPPLY
175
Linkages and A fjilititions in Training and Employment
Linkages among colleges and high schools are playing an increasingly
imporlant role in encouraging the training of minority allied health professionals. Directors of allied health programs with and wiihout HCOP grants
acknowledge their value in recruiting students. It appears that linkages
with high schools for t ea nil ment purposes are becoming formalized, perhaps in response to HCOP's continued emphasis on such linkages since
1981. Data show that there are mote linkages between schools and 4-yeai
historically blac k colleges and universities than between high schools and
community colleges. However, some schools that today lack community
college linkages report plans to explore these arrangements. Linkages appear to work well when there is shared commitment and mutual benefit,
regardless of wheiher the arrangement is formal (as in a written agreement
that specifies responsibilities and benefits) or informal (a working relationship).
"The predominantly minority schools contacted by the committee reported no difficultiesin finding adequate clinical placements for their students. These placements were most often in areas with large minority
populations. Today, programs are quite dependent on hospitals for placements and have limited experience with other kinds of sites for student
clinical training; thus, clinical training may be threatened if hospital revenues are reduced. Yet, several schools reported that clinical sites pay the
tuition for students they accept for clinical placements, usually because the
hospital is interested in hiring students who train with them. This interest
should help sustain affiliation agreements between schools and hospitals,
especially if workers are scarce.
No strategy for significant increases in minority participation in the allied
health professions will be successful unless it directs resources toward the
major barriers to minority participation and involves the complete spectrum
of interested parties, both in government and in the private sector. Minority
recruitment efforts must begin before high school. Academic institutions
must offer support services for retention and seek to promote educational
mobility. To succeed in the long term, these efforts must be made integral
to the mission of the educational institutions.
Ultimately, success will depend on the ability of educational institutions
to make a long-term commitment to integrating minority recruitment and
retention into the fabric of their allied health programs. The erosion of
federal support for this objective would undermine those in the education
community who are struggling to gain or maintain such a commitment to
minority allied health education. The committee endorses the objectives
of HCOP and believes that funding levels must be maintained at least at
current levels.
�176
ALLIED HEALTH SERVICES
M A I N T A I N I N G A N D EXPANDING
EDUCATIONAL CAPACITY
The future supply of new graduates in allied health fields depends not
only on students' careers bu, also on the maintenance and ex, ,n km c
educational opportunities.
expansion ot
Hospital-sponsored allied health education ,„,,,,„,„„
_
ures than any other types of programs. Hetween 1 ! ^ and 198 ' r,
hospital-sponsored programs closed, compared with a small ....mter'o"?
proprietary school closures. Hy contrast, there was a net increase in ,„
grams at community colleges (100 new prog, ams, or 9.6 percent) and junio,"
colleges (2b new programs, or 4 percetu) (CAHKA, 1987a). Table 5-3 shows
the net change between 1982 and 1986 in selected C A H E A « C C T £
alhed health programs. Much of the decline in allied health e d u Z v
s l l ( T
r
i
b
U
f
e
d
to the
d O S , , , g
0 f
e r c d
m
o
n
d o
h
7 ^
m" ' r
.
<*P^'-'-ed t r ^ Z g
g,ams-p, mctpally programs m laboratory and radiol<,gic technoloi Pr
grams that have the largest number of w i t h d r a w L f m C A H . A
accreditation (and that are presumed by CAHEA to have cl se t e me^
.cal technology (116), radiography (.03), and respiratory , S
techno "
ogy at the certificate level (29) (CAHEA, 1987b)
Among programs that are not accredited by CAHEA, physical thennv
y
P y
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
177
There is no clear evidence that capacity in higher education institutions
is in serious jeopardy. Nevertheless, program closings, coupled with fears
of a decline in the number of applicants, have heightened allied health
program directors' feelings of vulnerability. These feelings, which were
expressed by educators to the committee during its deliberations, arise from
a threefold concern: (1) allied health education will not be able to maintain
its foothold in research universities; (2) clinical education sites will grow
scarce; and (3) financially stressed educational institutions of all types, vie wing allied health as a costly endeavor, will close allied health programs.
Given the nation's projected need for allied health personnel and their
relatively short stay in the allied health work, force, any set ious erosion of
the education sector's capacity to supply the nation with allied health personnel must be avoided. The question for public policy action is whether
vulnerability poses a real and present danger that cannot be addressed by
market forces alone. I f government intervention or private efforts, or both,
are required, what actions will offer the greatest return on public and
private investments? To answer this question, we must first understand the
roles of various important decision makers and how their actions can
strengthen or weaken allied health education programs.
Who Influences Educational Capacity Decisions?
1981 to 97 programs in 1985-1986; masters degree programs increased
4
aZn! !987 )
dUring
^ ^
^
^
I
^^^^^^^
Number ol
CAHKA-Accredited Programs
Negative Change
Medical laboratory technician (ccrtilicale)
Medical technologist
Kadiogiapher
Kcspiratory therapy technician
Nuclear medicine technologist
Medical iccord administrator
Positive Change
Medical record technician
Occupational therapist
Medical laboratory lechnician (associate
degree)
Kcspiratory therapist
SOURCE: CAIIF.A (1987a).
Number of
Programs
in 1982
Programs
in 198(>
Percentage of
Change
73
639
790
188
138
57
47
516
701
169
128
53
- 35.6
- 19.2
-11.3
- 10.1
-7.2
-7.0
8r>
56
87
63
2.4
12.5
187
204
214
235
14.4
15.2
The decisions to open or close allied health programs or to expand or
contract enrollments are ostensibly in the hands of educational institutions
themselves. Typically, a dialogue occurs between a dean or department
head and the chief administrator for academic affairs about the desirability
of adding programs or the need to close or reduce the enrollment level of
a program. The remarks of one university president who was responsible,
earlier in his career, for manpower projections at one of the allied health
professions associations provide some interesting insights into the context
of this dialogue:
It obviously becomes extremely dif ficult for a university president to justify the
continuation of this or any other program when student demand has moved elsewhere, say, to real estate, and when the dean of the school of business is clamoring
for those scarce resources to be diverted to their front. Further, since the average
age of my faculty is only 49, natural attrition does not facilitate resource shifts.
It would be easier for me to justify maintenance of high cost programs if external
support were still flowing to my campus; however, as you are well aware, there has
been a steady decline in the amount of federal dollars available for health education.
Therefore, academic administrators are on the horns of a dilemma, and now, like
health care administrators, we must monitor the environment continuously and
respond to changes as never before. Strategic planning is the name of the game.
Universities can no longer afford to be all things to all people. (Perrin, 1987)
�178
At.UED HEALTH SERVICES
Decision making does not take place in isolation, and many parties can
be involved in precipitating a dialogue and iidluencing ils course. These
parties include federal agencies such as the liureau of Heallh Professions,
state higher education and licensing agencies, slale political leaders, accrediting bodies, professional associations, and local health care providers.
At times, the pressures exerted by these parties and conversely, the opportunities they have offered schools, through giants, for example, so
overwhelm institutional autonomy that it is difficult lo discern where control lies.
The issue of control is imporlant: by understanding the distribution of
authority over allied health education, we can identify how the forces that
shape decisions about educational capacity can be inlluenced to accomplish
public policy goals. These goals encompass nol only the size of enrollments
but the (juality of education, ils content, and the ability ofthe educational
system to add lo the nation's work force.
The Federal Role
A major, direct influence on the development of allied health manpower
training capacity has been the federal Bureau of Health Professions and
its predecessor organizations.
In 1966, not long after Congress enacted federal education funding for
medicine, osteopathy, dentistry, veterinary medicine, optometry, podiatry,
and pharmacy in one law and nursing under another authority, it also
provided education funding for 13 allied health fields. The Allied Health
Professions Personnel Training Act of fered five types of giants:
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1. Construction grants for training centers and affiliated hospitals.
2. Basic improvement giants awarded on the following formula: $5,000
times the number of eligible curricula in the center plus $500 times the
number of full-time students receiving training.
3. Grants to support traineeships for allied health personnel to hecome
teachers, administrators, or supervisors or to serve in allied health specialities.
4. "New methods" grants to allied health training centers for projects
to develop, demonstrate, or evaluate curricula for the training of new types
of health technologists (U.S. Department of Health, Education, and Welfare, 1979).
5. Special improvement giants to support projects or centers that would
provide no fewer than three curricula with the aid of this funding.
Table 5-4 shows the funding history of this law and its successor pieces
of legislation. Although no federal programs have specifically supported
allied health training since 1981, allied health students and schools are
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�ALLIED HEALTH SERVICES
180
eligible for funds under several general bealth professions education authorities, including
• the federally-insured HEAL Student Loan Program;
• educational assistance to disadvantaged students; and
• health professions special initiatives (grants for special projects in areas
such as health promotion and disease prevention; curriculum development
in health policy, clinical nutrition, and the application of social and behavioral services to the study of health cate deliveiy; the development of
mechanisms lor ensuring the competence of health professions; and the
development of instruction, including clinical af filiations, in geriatrics).
Efforts to assess the impact of federal funding have been stymied by a
lack of data. A major federal report on allied health concluded the following:
It appears that it [federal funding] added impetus to a trend that was already
underway . . . much of the private sector growth in educational programs that
occurred between 1J66 and 1971 without allied health grant support may have
occulted in expectation of federal assistance. Quite apart from the question ofthe
relative importance of federal suppoi t in increasing allied health manpower output
is the problem of determining what the increase was and where it occurred. Prior
to establishment of a federal role in allied health manpower, there was insufficient
interest in the problems to allow the collection of data on educational programs.
Not until 1972 was reliable information obtained on the type and amount of training
offered by colleges and universities. Some collegiate program growth occurred at
the expense of hospital-based programs and on-the-job training, another factor for
which there are no reliable data. (Bureau of Health Manpower, Health Resources
Adminisiration, 1979)
(
Other segments of the federal government have also played roles. The
Health Care Financing Administration, ihrough the Medicare program,
has provided support for clinically based education. The Department of
Education has helped through its general support of higher education loans
and scholarships and in its specific provision of vocational-technical training. The Veterans Administration and the military services have also played
a part in civilian training as they train personnel for their own needs. Finally,
the Department of Labor has been concerned with entry-level occupations,
offering training through the Comprehensive Employment Training Act
(CETA) program and later through the Job Partnership and Training Act
GPTA).
The State Role
Through their involvement in higher education financing and regulation, states are a major force in determining the number and distribution
EDUCATIONAL POLICY'S ROLE IN INELUENCINC, SUPPLY
181
of allied health programs. In 1976 (the last year of complete data), 71
percent of public collegiate institutions had at least one allied heallh program, but only 36 percent of private schools of f ered allied health education
(National Committee on Allied Health Education, 1980).
Fhe propensity to invest in allied health education depends in part on
the heallh of the state's economy. In one of its workshops the committee
explored decision making in three stales—Texas, Illinois, and New York.
Participants included representatives of highei education coordinating authorities, general collegiate administrators, and allied health school deans
f rom different types of instilulions. Fhey described decision making and
a sense of vulnerability that was related to the economic health of their
regions.
'
Allied health program administrators in Texas, where tax revenues have
been falling because of the declining oil industry, felt at greatest risk. The
Texas allied health educators believed themselves to be the first line of
defense against medical school cutbacks.
The economic situation was somewhat better in Illinois, but overall state
highei education cutbacks were forcing state college systems to plan their
responses to budget cuts if a pending tax increase did not occur. One
school system, having already raised tuition the previous year, had directed
its deans to considei the implications of a 5 percent budget reduction. The
options available to one allied health dean included the following: (1) not
filling vacant faculty positions, (2) offering some courses once instead of
twice that year, (3) canceling planned equipment purchases, and (4) closing
the school's physical therapy program, which needed more space.
At the time of the workshop, New York Slate deans and policy of ficials
were focused not on budget cuts forced by the state's economic picture but
on the state's responsibility for ensuring an adequate supply of health care
personnel. A state health department task force had recently been formed
to explore "critical shortages" in nursing, home health care, and physical
therapy services. One issue prompting the creation of the task force was
the inability of state chronic care facilities to recruit therapists. Deans attending the committee's workshop identified faculty shortages as a major
impediment to expanding education programs and enrollments in physical
and occupational therapy.
Statewide planning frequently occurs under the auspices of state higher
education coordinating bodies, which are responsible for approving new
education programs. In evaluating new programs, the coordinating bodies
consider such issues as geographic maldistribution of programs and practitioners and the impact of new programs on minority participation. Decision makers who participate in this policy arena often must be reconciled
to the fact that the politics of higher education planning (deciding, for
example, which among competing institutions should receive^the new proc^^ ie
�182
ALLIED HEALTH SERVICES
grain) may not lead to the conclusions that make the most sense from a
health planning standpoint.
States emphasize diffcrcni values in theit review of criteria for new
programs. Missouri notes that its "State-wide review is principally interested
in the stale's need for programs and services, and resource allocation issues.
That is, the statewide need for particular programs and the appropriate
means of financing these needs to assure Missouri's citizens financial access
to quality educational experience" (Missouri Coordinating Hoard for Higher
Education, 1986). In contrast, Texas has slated that "The expenditure of
public tax funds for educational programs in any occupational area is a
matter of public policy directed at meeting a public need that cannot or
will not be met otherwise. Student interest is not the major concern for
expenditure of public tax funds for an occupational training program"
(Allied Health Education Advisory Committee, 1980).
The ability of state coordinating bodies lo enforce their resource allocation policies varies. Some slate authorities may only be able to apply
"jawboning" tactics to influence institutional decisions. In some cases, battles
are fought during the state legislature's higher education budgeting process—through a specific line-item request for a new program, for example.
Depending on stale political tradition, legislators may choose to wield influence in favor of constituent educational institutions and in response to
lobbying efforts. More often, however, the survival of allied health programs is brought into question when academic institutions find themselves
forced to reallocate institutional resources as a result of a budget crisis. In
some states, higher education coordinating/governing bodies have statutory
review powers for new programs.
The Private Sector Role
T he private sector role can be seen in the activities of accrediting bodies,
professional associations, and foundations.
Accrediting Bodies There are a multiplicity of issues surrounding who
should control accreditation, how it should be structured, and whether it
could be a less costly process. This discussion, however, will focus on accreditation standards, which have a major impact on collegiate decision
making about new or expanded programs.
Program administrators must take into account the cost of complying
with the standards of accrediting bodies and the recommendations of site
review teams. For example, programs sometimes close because they cannot
maintain tbe student-faculty ratios, equipment, or space required by an
accrediting body. Often, there is a clash between the accrediting body
(which believes its essentials ensure basic minimum standards) and gen-
EDUCATIONAL POLIO'S ROLE IN INELUENCINC, SUPPLY
183
eralist academic administrators (who see site review recommendations as
a tool to be used by departmental chairmen to gel more suppoi t for their
programs).
Professional Associations Historically, much of the educational activity of
allied health professional associations has been in promoting the shift of
educational programs from hospitals to academic instilulions. Once this
shift was accomplished, an association's interest often centered on raising
the entry level of the profession or on creating assistant-level categories of
personnel.
•
Today, associations' educational activities range more widely. They might
include consultation to academic institutions contemplating new program
offerings, workshops for administrators and faculty, student recruitment
programs, and the maintenance of education data bases. Some associations
have assumed quasi-regulatory functions in the education accreditation
arena. For example, accreditation responsibilities for dietetics, physical therapy, and speech-language pathology and audiology are handled through
independent entities operating in conjunction with the professional associations. It should be noted, however, that some ofthe allied health fields
do not have a well-organized professional association that can engage in
educational activities.
Supplementing the work of the associations are the American Society of
Allied Health Professions and the National Society of Allied Health—two
umbrella organizations that cut across disciplinary lines in an effort to help
their members address educational issues common to most fields.
Hecause of an extensive literature and the activities ofthe Federal Trade
Commission in questioning the role of the American Medical Association
in limiting the supply of physicians through medical education, it is reasonable to raise the question of whether allied health associations influence
the supply of practitioners in their respective fields, restricting entry as a
means of enhancing the economic status of their members. An investigation
to determine such influence, however, was beyond the scope ofthis study.
Private Foutulations Complementary to the role of federal and state support is the contribution of philanthropy in generating experiments in allied
health education. Principal among tlie foundations is the W. K. Kellogg
Foundation, an organization that over many years has spurred institutional
development and leadership activities and studies of allied health fields.
Currently, the foundation is supporting a clearinghouse at the University
of Alabama to clarify and promote the concept of mullicompetency in
allied health as well as supporting several activities ofthe American Society
of Allied Health Professions.
�184
ALLIED HEALTH SERVICES
Why Is Allied Health Education Vulnerable?
As indicated in the previous section's review of federal, state, and private
roles, the era of direct efforts to expand the allied heallh education enterprise has ended. Yet the day-to-day business of federal, state, and private
decision makers continues to shape allied health education. Federal Medicare reimbursement policy, state higher education budgeting and regulation, interest groups in pursuit of enhanced professional status, and
educational accreditation are all powerful influences on the f uture of allied
health education. How stable educational institutions will be in the f uture
will depend on their ability to compete for higher education resources with
other, more entrenched academic programs whose graduates may also be
in high demand.
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A number of prestigious institutions—the University of Pennsylvania,
University of Michigan, Emory University, and Stanford University, for
example—have closed allied health schools and programs. A fundamental
component of the rationale for closure appears to have been that the
preparation of allied health practitioners did not suf ficiently contribute to
the aspirations of a research university seeking to concentrate its resources
in areas of strength. As allied health deans see some of the most noteworthy
programs close, they grow apprehensive about the future of their own
programs. They are also concerned about the f uture of allied health programs because the programs lack the capacity to foster research and produce teachers and academic leaders (Broski et al., 198!); Hedrick, 1985).
Although it is difficult to document the f ragile condition of allied health
education, the committee believes there is some basis for the deans' apprehension. Furthermore, the committee is concerned that closures have
signaled to academic decision makers and public of ficials alike thai allied
health education may not be a sound investment for scarce educational
dollars.
As Table 5-5 (which is based on 1970s data from the National Commission on Allied Health Education) shows, these programs have long
existed in almost every type of collegiate institution. Fhe committee believes
that there is no generic or inherent quality that disqualifies allied health
education from life on any campus in the naiion. T he diversity and evolution of the many occupations suggest that some are more suited than
others to various academic settings and degree levels. Yet the conclusions
that are drawn today about a given field may change tomorrow as knowledge and practice evolve. Each type of collegiate setting has its advantages
and disadvantages. Generally speaking, for example, academic health sci-
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Number of Such
Institutions in the
United States
Number and Percentage with
Allied Health Programs
Number
Percentage
Percentage of All
Allied Health
Programs in Such
Institutions
Comprehensive universities and colleges I
Institutions offering a liberal arts program
and several others (e.g., engineering,
business administration) that have at least
two professional or occupational programs
and enroll at least 2.000 students. Many
have master's programs and, at most, limited
doctoral programs.
380
302
79
22.76
Comprehensive universities and colleges I I
State colleges and some private colleges that
offer a liberal arts program and at least one
professional or occupational program (e.g.,
nursing or teacher training, mainly with a
degree in education).
217
135
63
Liberal arts colleges I
Highly selective or among the 200 leading
bachelor's-granting institutions in terms of
numbers of graduates receiving Ph.D.s at 40
leading doctorate-granting institutions.
126
27
21
0.75
Liberal arts colleges I I
Other liberal arts colleges, many of which
are extensively involved in teacher training,
granting degrees in arts and sciences rather
than in education.
474
243
51
3.33
Type of Institution
Two-vear colleges and institutions
Theological seminaries, bible colleges, and
other institutions offering degrees in religion
1,135
59
35.18
277
9
0.07
Medical schools and medical centers
Includes only those that are listed as
separate campuses in USOE Opening Fall
Enrollment.
51
35
69
3.95
Other separate health professional schools
29
/
24
0.17
Schools of engineering and technology
Technical institutions are included only if
they award a bachelor's degree and if their
program is limited exclusively or almost
exclusively to technical fields of study.
47
10
21
0.5
Schools of business management
Included only if they award a bachelor's or
higher degree and i f their program is
limited exclusively or almost exclusively to a
business curriculum.
35
13
37
0.3
Schools of art, music, design
58
3
0.05
Schools of law
16
13
0.05
Teachers colleges
28
18
0.32
Other specialized institutions
Includes graduate centers, maritime
academies, military institutions (lacking a
liberal arts program), and miscellaneous
others.
35
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�188
ALLIED HEALTH SERVICES
ence centers have easier access to clinical resources and a wide range of
opportunities lor interdisciplinary experiences. However, as reported to
the committee, the latitude lot decision making and creativity of program
design hy deans and program directors has traditionally heen mote limiied
in academic health science centers than in schools of allied health that are
independent of such centers. Communiiy colleges shine in their ahility to
attract to diverse student populations who are job oriented. Educational
programs there are tailored to suit the needs of employers and students
in a given local community.
To guide institutions in deciding whether to continue or start allied health
educadon programs, the Southern Regional Educalion Board (1980) suggests that the following six questions he considered:
1. Mission Is the program consistent with the institution's philosophy
and pui pose?
2. Employment Will graduates be able to secure employment and will
that employment satisfy the local, state, regional, or national mission of the
institution?
3. Accreditation Is the institution willing to invest in a program, given
the resource consumption implicit in achieving accreditation?
4. Students Will there be sufficient enrollment over a sustained period
of time?
5. Budgetary concerns Is the institution prepared to adopt programs in
which clinical components may require equipment, supervision, and costs
that often exceed those of other types of academic programs?
6. Faculty Is there a sufficient faculty pool on which to draw? What
resources will be necessary to attract qualified individuals to teach?
Today, allied health education appears vulnerable on all but the 'employment demand' criterion. The key to improving allied health's bargaining position in academia is to demonstrate value to the parent institution
that is striving to fulfill its mission of scholarship or community service.
The recommendations that follow are designed to address some of the
problems that prevent allied health programs from competing effectively
for institutional resources and thus endanger their viability.
Faculty Shortages
Because many allied health fields are relatively new to collegiate environments and have grown rapidly in the past 2 decades, allied health
educational programs often face both quantitative and qualitative problems
in filling faculty positions. In physical therapy, for example, the number
of accredited university programs grew from 48 in 1970 to 113 in 1986.
The supply of faculty does not appear to have kept pace. A 1985 survey
of academic administrators in these programs reported a need for 152
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
189
additional faculty simply to meet current demands (American Physical
Therapy Association, 1985). As a result, many programs rely heavily on
part-time lecturers without regular faculty appointments, faculty from scientific disciplines who do not hold professional qualifications in die clinical
field, and professionals who lack the academic credentials that are traditionally expected of university faculty. For example, in its faculty survey
the American Physical Therapy Association reported that only 28.2 percent
of full-time faculty in physical therapy programs had doctoral degrees.
This proportion was in clear contrast to national dala that showed thai 54.9
percent of all faculty teaching in institutions of higher education had doctorates (Newman, 1985). Fhe recruitment of qualified new faculty is seriously hampered by the very limited pool of candidates. Even in relatively
mature occupations such as occupational and physical therapy, professional
associations report that only about 1 percent of all members have doctoral
degrees and just over 24 percent have master's degrees (American Physical
Therapy Assocation, 1987; American Occupational Therapy Association,
1987).
In a survey of 124 medical record education programs (which constitute
more than 80 percent of all programs), the majority employed only one
or two additional faculty members besides the program director; no program had more than four full-time additional faculty. Only five of the
directors of these schools had a doctorate. Among the 53 full-time faculty
members in university-based programs, only 2 had doctorates, 33 had
master's degrees, and 18 had baccalaureates as their highest academic degree (Amatayakul, 1987).
Although some allied health professionals are enrolled in master's and
doctoral degree programs, the lack of financial aid and the relatively low
earnings of allied health clinicians force most of them to carry out this
advanced study on a part-time basis over a long period. Lack of funding
has also constrained the development of graduate programs in several allied
health disciplines. Although advanced study in such related disciplines as
physiology, psychology, or education benefits allied heallh faculty, the lack
of graduate programs in their own disciplines has limited the number of
allied health faculty who are active scholars in the field in which they have
the greatest teaching responsibility.
The options for producing faculty efficiently should be explored to maximize faculty development resources. The American Occupational Therapy
Association has had some success in targeting faculty development efforts
toward clinical faculty who might be inclined to pursue full-time teaching
appointments (S. Presseller, American Occupational Therapy Association,
personal communication, 1987). Another approach would be to focus attention on streamlined allied heallh certificate programs that give individuals with doctorates in other academic disciplines the opportunity to gain
�190
ALUM) HEALTH SEIIVICES
a practice credential for teaching purposes. Holcomb and colleagues (1987)
have described a partnership between Baylor College ol Medicine, Texas
A&M University, and the University ol Houston that oKers programs in
allied health teacher educalion and adminisiration that have been productive in supplying faculty nationwide.
The rationale fbr a federal role in faculty development in allied heallh
is similar to the justification for federal suppoit of family practice programs
in medicine, f r o m 1972 through 1984, federal grams of more than $201)
million fostered the growth of graduate family medicine training activities
(Heaith Resources and Services Adminisiration, 1980). Tike allied health,
family medicine exists today because the federal government was willing
to promote a concept that was designed to address some of the health care
system's deficiencies. As a relatively new endeavor, family medicine departments still lack qualified faculty and the ability to garner research funds
from traditional sources such as N I H , in part because of noncompetitive
research credentials among faculty and in part because of the low f unding
priority of primary care research. Like allied health, family medicine has
yet to prove itself to the academic medical center establishment—a task
that is hindered by a reimbursement system that does not generally reward
non-procedure-oriented faculty practice.
Federal grants are being used to make the playing field more level for
family medicine in lhe competitive medical school environment. Federal
investment in family practice is based on the policy assessment that primary
care needs are unmet and that these programs are a cost-effective means
of producing and distributing primary care piaciitioners. Similar national
goals relating to issues of rehabilitation, disease prevention, AIDS treatment, and geriatrics can be well served by the support of allied health
education.
The committee recommends that federal and state governments fund
faculty development grants in allied health fields, especially in areas in
which faculty availability and lack of clinical expertise inhibit the production of entry-level practitioners.
Closely lied to the need to improve teaching faculty is the need to advance
research in allied heallh. Research and oilier forms of scholarly activity are
inherent features of academic life. Programs that fail to give sufficient
weight to academic research, along with teaching and service to the institutions, are doomed to instability over the long run. In recognition of this
fact and with the belief that the practice of any large group of health care
professionals ought to be informed by an increasing knowledge base, the
1983 IOM study of nursing recommended that the federal government
fund programs to increase the supply of doctorally prepared nurse researchers and suppoit "an organizational entity to place nursing in the
mainstream of scientific investigation" (Institute of Medicine, 1983). These
EDUCATIONAL POLICY'S HOLE IN INELUENCINC, SUPPLY
191
recommendations spurred die creation of the NIH Task Force on Nursing
Research and. eventually, congressional action that established the Center
for Nursing Research at N I H .
In its final report the NIH task force concluded thai the extramural and
intramural program activities then supported by NIH were consistent wilh
the mission of the institutes and that studies conducted with nurses as
principal investigators and studies designed lo improve nursing care (but
not necessarily directed by nurses) could be fostered thtough a combination
of activities. These activities were intended to help train mu se researchers,
encourage greater collaboration by and inieresi on the part of medical
scientists in inlerdisciplinary work, and enhance the capability of nurses to
compete for research suppoi t (National Institutes of Health, 1984).
Although there are few data to confirm the impression, it appears thai
the research capability of most allied health fields is less developed than
that of nursing. In part, this increased capability of nursing may be due
to the continuing commitment to research provided by the federal Nurse
Training Act (Title V I I I , Public Health Service Act) and the newly created
Center for Nursing Research within N I H . Covey and Burke (1987) offer
an additional explanation:
Because qualified faculty by the traditional standards were not available, selection
of our University faculty has often been largely liotn the practilioner ranks and
from those who had perhaps acquired graduate degrees in such unrelated disciplines as education or administi ation. The locus of their training has been on
technological competence and, in some cases, discipline pedagogy but has not always
included research. By virtue of their own training, deans and directors themselves
are often unable to develop the junior faculty and, in fact, too many deans and
program directors eilher lack an understanding of or simply ignore the tripartile
academic mission.
In later chapters of this report that deal with issues of health care management and regulation and with long-term care, the committee notes
decisions that administrators, payers, and regulators must make in the
absence of an allied health research literature. Medical scientists and other
researchers on their own will not and cannot define research priorities
f rom among heallh care services delivery issues or the clinical applications
that typically concern allied health practitioners. Although medical scientists
should be encouraged to develop collegial relationships and undei lake joint
projects with allied health personnel, they are not as likely to be interested
in the outcome measurement and cost-effectiveness issues that need to be
addressed as are those who deliver the services.
Allied health fields vary in their maturity with respect to a productive
research capacity. Some fields such as dental hygiene, in which most practitioners have less than a baccalaureate, are only now beginning to explore
�192
ALLIED HEALTH SERVICES
tlie possibilities of a cadre of research leaders to build a body of knowledge
linked to a theoretical f ramework. T his research should go beyond simple,
unrelated pilot studies. It should define dental hygiene as distinct from
dentistry and explore the efficiency of methods and modes of practice
(Bowen, 1988). In contrast, other fields like speech-language pathology
and audiology have many practitioners with master's degrees and doctorates and a rich history of tapping into a growing knowledge base in human
communication services and disorders. Both fields, however, share a concern over the lack of relevant research finding its way to those who provide
patient services—whether it be to the communicatively impaired (Ludlow,
1986) or to those seeking preventive set vices f rom a dental hygienist.
A cadre of researchers and academic leaders is needed to advance the
sciendfic base of allied health practice. To accomplish this goal, institutions with strong research commitments should consider developing
programs that identify and nurture talented individuals. The committee
recommends that a federal research fellowship program be insdtuted to
support these activities.
Financing Clinical Education
The closing of hospital education programs discussed earlier in this
chapter represents more than a long-term shift from hospital-based to
academically based education. Hospitals with limited resources may reduce
or eliminate clinical affiliations with education programs in addition to
closing their own sponsored programs.
As clinical affiliates attempt to trim their costs in response to reduced
revenue, educators fear that hospitals will request remuneration for the
supervision of students or seek other means of shifting costs back to the
educational institution. As of 1987, it appears lhat this is not a large problem. When CAHEA (in press) queried education directors about changes
over the past 3 years in the costs of the clinical portion of their programs,
it received the following responses: 17 percent said they had experienced
significant cost increases; 13 percent felt that program viability was threatened; and 15 percent perceived that the program had become a burden
to the sponsoring institution. Only 7 percent reported a significant change
in curriculum. Allied heallh educators are also concerned about long-standing proposals to constrain or eliminate Medicare paymenls for educalion.
Currently, Medicate pays hospitals for the direct educational costs of allied
health programs on a reasonable cost basis as an addition to the DRG
paymenl. Payments are intended for provider-operated programs and not
for affiliated programs in which the hospital provides part of the clinical
training in a university-based program. For the latter, the costs of the
training and ils benefits to the hospital are presumed to balance one an-
EDUCATIONAL POLICY'S ROLE IN INELUENCINC, SUPPLY
193
other. Since the passage of PPS, there has been some confusion over whether
the costs of jointly sponsored programs are eligible for reimbursement.
Presidential budget proposals to terminate Medicare funding for hospital-based allied health and nursing education programs have added to
concerns that hospital financial managers, who are looking for every opportunity to reduce institutional costs, will eliminate clinical affiliations
whenever feasible. To those attempting to find ways to reduce the federal
budget, the direct support of educational programs represents an openended expenditure lhat is insufficiently targeted to the most important
national human resources needs. Mosi often, these are thought to be the
development of greater numbers of primary care physicians and fewer
specialists.
Several recent studies sponsored by the Health Resources and Services
Administration to assess the impact of proposals to eliminate Medicare's
educational support have provided a better understanding of the role
played by this source of educational financing. A congressionally mandated
study of nursing and nonphysician (i.e., allied health, as defined by the
study) costs in educational programs approved for Medicare reimbursement, conducted by Applied Management Services, Inc., revealed that,
logeiher, these programs cost Medicare roughly $226 million in the second
year of prospective payment. T his figure is relatively small compared with
the $42.7 billion the governmeni paid to hospitals under Part A Medicare
for the same period. The analysis of Medicare cost reports indicates lhat
nonphysician health care education programs cost the 514 providers in the
program a total of $167 million. Nursing programs were more expensive,
costing 547 providers $533 million (Health Resources and Services Adniinislration, 1987). Medicare pays only for ils own share of the allowable
direct costs.
Other studies (Lewin and Associates, 1987; Mathematica Policy Research,
Inc., 1987) have confirmed the observations of Applied Management Services in interviews with the directors of hospital educalion programs. Education programs of fer numerous benefits to the employer, chief of which
is the opportunity to recruit future employees. Additional benefits include
motivating existing staff to stay abreast of advances in their fields, and
enhancing the reputation of the hospital by providing a community service
to local educational institutions.
The committee believes that the federal government should not reduce
its support on the presumption that employers—realizing the benefits of
education programs—will maintain and even increase their support. Precipitate action to cut Medicare's educaiional suppon runs the risk of destabilizing vulnerable allied health education programs. In the committee's
view, such destabilizalion is not worth relatively small, shon-term budget
savings. In the long run. Medicare beneficiaries would be harmed by lim-
�194
ALLIED HEALTH SERVICES
iting dinical experience for students. Moreover, many of ihese costs are
likely lo emerge later as potentially more costly recruitment and on-thejob training expenses.
Therefore, the committee recommends that, until credible alternative
approaches are developed, the federal government and other third-party
payers maintain current reimbursement levels and mechanisms of support for clinical allied health education.
The Comjjinalive Cost of Allied Heallh Education
Allied education programs are perceived by educational planners and
administrators to be high-cost programs. As a consequence, ihey can be
prime targets for institutional budget reductions by central administrative
staff. Where state highei educalion funding formulas do not compensate
for Ihese higher costs, programs are exceedingly vulnerable to cost-cutting
measures when times are hard in highei education.
There has been growing recent interest in constructed cost models to
improve the ability of allied health deans and program directors to negotiate
with their central administration and explain why their unit costs may be
higher than those of other fields. T hese models focus on key assumptions
about faculty contact hours, faculty-student ratios, resource requirements
for clinical experiences outside the department, and faculty salaries (freeland and Gonyea, 1985). Although the models are useful tools for improving efficiency and then demonstrating those improvements to academic
administrators, their explanatory power does not change the reality that
allied health education is faculty intensive, that it necessitates clinical education experiences requiring coordination and supervision, and that it
often has extensive laboratory and space requirements.
The recommendations that have already been made in this chapter will
help to address some of the weaknesses allied health programs have in
competing for resources. Yet these measures are no substitute for the
actions many allied health schools must begin to take to generate the revenue needed to thrive. Medical schools have come to rely increasingly on
income generated from faculty practices. Although such activities may not
be appropriate or financially advantageous fbr many allied health fields,
they may be so for some if they are established with sufficient forethought
and expertise. The notion of generating revenue by providing services
needs further exploration, however. For example, the services provided
by allied health schools might be educational (extension courses or adult
education, for example), or they could involve innovative relationships with
industry.
To enhance the stability of allied health education, national organizadons such as the American Society of Allied Health Professions should
EDUCATIONAL POLICY'S ROLE IN INELUENCINC SUPPLY
195
investigate models in which academic institutions have succeeded in
broadening their financial base through such mechanisms as faculty practice plans, extension courses, and industry relationships. The national
organizations should also hold workshops to help institutions implement
the models and to disseminate information.
In undertaking revenue-generating enterprises, however, allied health
deans will confront and possibly exacerbate a problem they have faced
before. Faculty resources currently arc stretched thin to control costs, and
the excessive teaching load leaves little time for faculty to engage in scholarly
activity, research, and college committee work. Yet these activities constitute
a major portion of the traditional evaluation criteria for faculty promotion
and tenure. Consequendy, they are the preferred nonteaching activilies
pursued by faculty wishing to advance their academic careers. Maintaining
state-of-the-art clinical competence further adds to the faculty's already
excessive work load. Indeed, the committee heard a numbei of deans
complain of the difficultiestheir faculty members f ace in maintaining clinical skills and of the concomitant impact of these dif ficulties on preparing
students for the labor market.
To ensure that the clinical competence of allied health faculty is maintained, the institutional award system must accommodate clinical competence because faculty allocate what little nonteaching time they have to
those activities that are highly rewarded. The committee recommends that
institutions that offer allied health academic programs reward and encourage faculty clinical competence. Clinical practice that sustains this
competence should be made a requirement for promotion.
It is noteworthy that this concern about the reward system is also one
that medical educators have been forced to confront. As the president of
the Association of American Medical Colleges has observed, "Despite the
realization that teacher-clinicians are essential ingredients of medical facilities, the need is often not recognized by the parent universities whose
appointments and promotion policies leave no niche for the clinicianteacher to receive proper recognition" (Petersdorf, 1987).
Preparing Students for Tomorrow's Jobs
In principle, sound educational planning would dictate that academic
institutions base their program offerings on an understanding of the knowledge, skills, and socialization required of their graduates—not only for
today's health care labor market but for the future as well. By extension,
statewide higher education planning should take into account the mix and
distribution of personnel at different educational levels that will be needed
across the state. Confounding efforts at such rational planning, however,
are a lack of clear signals from the labor market about future human
�196
ALLIED HEALTH SERVICES
resource needs and continuing controversy about matching education to
the requirements of the health care delivery system.
Reflecting this controversy, an allied health education advisory committee
in I exas highlighted a series of concerns that often surface when such
groups view the broad spectrum of allied health fields (Allied Health Education Advisory Committee, 1980):
• the growing amount of narrow specialization at all degree levels• the requirements of some professional groups lor higher levels of
training for professional entry credentials;
• difficulties with the transfer of credits to implement tbe career ladder
concept;
• the most appropriate levels of training for various kinds of allied health
personnel; and
• differences in the programs needed to prepare practitioners, master
cfimcians, teachers, researchers, and managers.
Ironically, these issues are of concern today because, in the past educational institutions have responded to student and employer demands
Associate degree and certificate programs were developed to provide students who were unwilling or unable to spend 4 years in school before
entering the work force an opportunity to enter a field in which those
workers with traditional higher credentials were in short supply. Academic
health centers and 4-year colleges, in addition to community colleges, sought
to meet the needs of their own and local hospitals with 2-year programs
Students with baccalaureates in other than health care fields were accommodated w.th certificate programs so they could pursue allied healtl, careers. Students who were interested in careers in respiratory therapy, dental
hygiene and radiography, which were principally offered at the associate
degree level, found themselves able to enroll in programs that also allowed
them to obtam baccalaureate degrees. The result of these developments
pams
"
P
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1 8
0
f
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O C C U
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t o
a
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Having accommodated the needs of different student markets and employets who were either experiencing shortages in some personnel categories or who were attempting to structure their staffing with personnel
of different educational levels, the educational system is now faced not
surpristngly, with a state of untidiness that planners find uncomfortable
Further compl.cat.ng matters is the growing availability of graduate training. Although advanced degrees have long been accepted as appropriate
preparation lor faculty, administrators, and researchers, there is greater
skepticism about graduate work when it comes lo the elevation of a field's
entry-level qualifications or efforts to develop specialities
EDUCATIONAL POLICY'S ROLE IN INFLUENCING SUPPLY
197
The committee acknowledges this great diversity in educational qualifications but finds that a public policy problem requiring attention may not
exist. Fhe diversity in and of itself is not a problem. T he test of whether
specialization and changing qualifications or standards are dysfunctional
is twofold: (1) Is there wastefulness in student educational investmenls? (2)
Is the educational system responsive to society's need for a manpower
supply lhat permits the health care system to function ef ficiently and provide care of the desired quality?
Educational Investments Iry Students
To open a new education program and admit a class implies a contract
with students that contains certain assurances. No school can guarantee a
student a job nor can it guarantee that skills and knowledge acquired in
its programs will be marketable in perpetuity. Nevertheless, the committee
believes that schools have the responsibility to ensure that (1) professional
education is training for a specific, "real" occupation at the end of the line;
(2) the program's general education contenl is sufficiently balanced by
occupation-specific skills; (3) if, and when, students wish career advancement through education, there is a relatively efficient pathway to follow;
and (4) there is a realistic balance between the role aspirations of professions
with the realities of day-to-day work. In fulfilling their responsibilities to
students, educational decision makers face a number of dilemmas.
"Real" Jobs There are numerous job titles under the umbrella of allied
health. Not all of them need to have separate, formal academic programs.
Yet educators must be sensitive to changing technology and disease patterns
that may warrant such recent developments as genetic counselors and MRI
technicians.
The Southern Regional Education Board (1980) has recommended—
and the committee concurs—that academic institutions contemplating the
development of new allied health specialities ask themselves three practicerelated questions:
• Are there any legal or professional restrictions on the new practitioners
that will tend to inhibit employers from hiring these graduates?
• Is the new speciality sufficiently dif ferent from existing specialities to
justify the development of a new educational program?
• What degree of liability does the supervisor of the new practitioners
assume?
Liberal Education Faculty in professional or technically oriented programs in higher education face a continuing struggle to reconcile the demands of academia for scholarship and general education with pressures
�198
ALLIED HEALTH SERVICES
from employers and accrediting bodies to prepare students for technologically demanding jobs. The argument on the side of liberal education is
that the educational program ought to be providing preparation for life
and not just for a specific job. Graduates must be prepared to respond to
the inevitable changes that will occur in society.
Many educators feel the pressure dial is exerted by employets (especially
employers in fields that require familiarity with instrumentation) to influence programs to produce graduates who do not need extensive orientation, f.ven at the community college level, which has had a strong tradition
of job orientation, there is concern about the appropt iate mix of general
education and technical/clinical course work. In one small survey, 25 allied
health community college deans reported proportions of general education
to technical/clinical course work credits that ranged from 8 percent to 35
percent, with an average of 22 percent (Kaminski, 1987). In the name of
responsiveness to a changing society, general educalion courses compete
with pressures to incorporate such areas of study as geriatrics, computer
applications, mullicompetency, and clinical experience in alternative sites
of care.
The committee is sympathetic to the dilemmas faced by curriculum planners. Yet it is also concerned that students receive an educational foundation on which they can build a career if they so desire. Part of this
foundation entails developing the capacity for and an interest in lifelong
learning. A further, important benefit of such a foundation is that, if
current skills become obsolete, practitioners have a base on which they can
develop an alternative career.
Atliculation Allied health dean Elizabeth King from Eastern Michigan
University describes two hypothetical students to illustrate the personal
dimensions of the problems of articulation, the process by which students
achieve upward educational transitions among academic programs (King,
1985). One student, having worked 7 years as a certified occupational
therapy assistant "with a love of the profession and a conscious decision to
build upon her current skills," is confused and disillusioned when denied
the opportunity to transfer her prof essionally related course work toward
an occupational therapy degree. Meanwhile, another student with an associate degree in general studies, hearing about the good job prospects for
occupational therapists but having little knowledge about what occupational
therapists do, is advised by the senior college that all of his courses will
transfer and he can complete the degree in 2 years.
In general, states have strongly promoted the concept of multiple entry
and exit points in health careers to minimize the loss of student time in
moving through certificate, associate, and baccalaureate programs. Without
EDUCATIONAL POLICVS ROLE IN INELUENCINC, SUPPEY
^
strong mandates or incentives, however, such programs have difficulty
-ercoming some inherent barriers. King discusses a number ol them. I o.
! an pie, curricula,- problems occur in judging the compatibil.ly of didactic
dinical program content, which makes i , difficult to assess advanced
ement. There is also, a. limes, a lack of commumcaLon between acae, i lai. s and admissions offices to work out problems regarding credi
n e policies. Finally, and perhaps most important, faculty profess.ona .
i se it King's view, "the most insidious barrier," create an environme, t
'.r'undiscuss^ble tension." These biases label community college students
•ts "ta hnically" trained and lacking in problem-solving experiences.
•n" comnuttee recommends lhat alternative pathways to entr^level ,
practice be encouraged when feasible. State higher ' ^ ^ ^ ^
Tng authorities and legislative committees should ms.st on flex.bdrty m
educational mobility between community colleges and baccalaureate programs.
Rolr Conmience There is continuing tension between health care ad^nistratoif and professional groups over the tendency of a field to assume
more sophisticated or broader responsibilities and the percep .on of employers (or payers) as to the legitimate and valued funct.ons lhat need to
be performed for patients.
,
.,:ua;,;„
Professional assoeialions and program faculty see the.r respons.bil.t.e
as the defining and shaping of their discipline. 1 his process is reflected m
, ctdum content and reinforced by
^
^
is.ra.o. s become concerned when they believe curriculum is be.hg used a
cursor to expanding the legal scope of practice and - - b u r s e m e t
wihoui recognition of what is possible or Hkely ,n
become concerned when they believe thai an ocxupat.on .s at « h e j a n «
time abandoning "hands-on" patient care fo, "professiotial lesponsibiht.es
that are not valued highly by those outside the field.
Care must be taken to ensure that students do ru*
^
these controversies. Ullimately, these .ssues are resolved by the marke as
shaped by consumer tastes and employer hiring practices or b pr»bl c
»ol cv as reflected in reimbursement or licensure dec.s.ons White these
sue 'are i S n g resolved, however, the committee believes that educators
1 v ,he r«po n,bility to ensure that students have reahstic expectations
of what their prospective occupation is like today-and not only what U
might be in the future.
s
g
The Agreement Between Education and Services
Along with the education program's responsibility to students is a responsibility to society to ensure that the health care system has the human
�MUED HEALTH
SERVICE
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�202
ALLIED HEALTH
SERVICES
they are frequently drawn into debates over licensure issues that involve
changing scopes of practice and the licensing of new occupations, ( rhese
regulatory issues are discussed in Chapter 7.)
Private foundations could have a major impact on the future of allied
health education and practice by creating . „tei.s of excellence in a lew
academic institutions. Many advantages might be gained by coalescing
core research faculty that also provides services. These mutually reenfotcing activities would enhance the quality of research and patient care TurIhermore, these centers might then be a resource to other allied health
education programs regionally or nationally.
"The committee believes that the interest of state legislatures and priv tie
foundations in the endeavors we describe will be kindled and sustained
only by a continuing federal presence in the concerns of allied health
education and practice. For this reason, the committee makes the iollowing
recommendation about the federal leadership: The Department of Health
and Human Services should maintain an organizational focal point on
alhed health personnel to implement the grant programs recommended
in this report, to coordinate the recommended work of the interagency
data task force (recommended in Chapter 2), and to facilitate communication between state legislative committees and the federal government
( {;
a
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Institute of Medicine. 1983. Nursing and Nursing Education: Public Policies and Private
Actions. Washington, D.C: National Academy Press.
Kaminski, G. 1987. Allied Health Study: T wo Year College Survey. Unpublished paper.
Cincinnati Technical College.
King. E. 1985. Articulalion of allied health educalion. Pp. 126-139 in Review of Allied
Heallh Education: 5. J. Hamburg, eel. Lexington, Ky.: University Press of Kentucky.
La Jolla Management Corporation. 1984. An Assessment of Preparatory Activilies for the
Health Careers Opporlunity Program: Final Report. Rockvillc, Md.: Health Resources
and .Services Adminisiration.
Lent, R., S. Brown, and K. Lark. 1986. Comparison of three theoretically derived variables
in prediciing career and academic behavior: sclf-efllcacy, inlcrcsl congruence, and
consequent thinkitig. Journal of Counseling Psychology 34(3):293-298.
Lewin and Associates. 1987. Hospilal Decision-Making About Offering Hcallh Professions
Clinical Education Opportunities and the Effects of Payment Policies on These Decisions. Final Report. Rockville, Md.: Health Resources and Services Administration.
May.
Ludlow, C. L. 1986. The Research Career Ladder in Human Communication Sciences
and Disorders. Bethesda, Md.: National Institutes of Health.
Malone, P. 1979. Creating New Allied Health Programs: Considerations and Constraints.
Atlanta: Southern Regional Education Board.
Mandex, Inc. 1987. An Assessment of State Supporl for Health Professions Educalion
Programs: Final Repon. Rockville, Md.: Health Resources and Services Administration. June.
Mathematica Policy Research, Inc. 1987. Draft final report on exploration of trends and
changes in clinical education in the preparation of allied health professions. Washington, D.C. June 30.
Miller, J. D. 1986. Multivariate models to predict the selection of and persistence in a
career in the professions. Paper presented to the 1986 annual meeting of the American
Educational Resource Association, San Francisco, April 17.
Mingle, J. 1987. Trends in Higher Educalion Participation and Success. Publ. No. MP87-2. Denver, Colo.: Educalion Commission of lhe States and State Higher Education
Executive Officers.
Missouri Coordinating Board for Higher Education. 1986. Recommendations to the Comminee on Academic Affairs regarding "State-Level Review of Existing Programs in
Health Sciences Education." Jefferson City, Mo. April.
National Commission on Allied Health Education. 1980. The Future of Allied Health
Educalion: New Alliances for the I980.S. San Francisco: Jossey-Bass.
New York State Education Department, Bureau of Higher and Professional Education
Testing. 1985. Program Guidelines. Albany: New York Slate Education Department.
Newman, F. 1985. Higher Education and the American Resurgence. Princeton, N.J.:
Carnegie Foundation for the Advancement of Teaching.
Parks, R. B., and H . L. Hedrick, 1988. Program directors' perspectives regarding CAHEAaccredited allied health education. Summary of a 1987 survey. Allied Heallh Educalion
Directory, 16th ed. Chicago: American Medical Association.
EDUCATIONAL POLICY'S ROLE I N INFLUENCING SUPPLY
) V r l
,
n
K i , . |987. Remarks a, ,he Symposi
on dte F
re of AHied HeaUh Educalton,
lw,, ,,ii,n,,iMK:,,,<, DcsiKni
sis SK--- —>
ration lor Program Rcv.cw. Ad.mla.
Ollicc August.
205
A,,ic<,, ,caW,Ktlu
"* '
,
l l c
"
Scncuny's Task
�I.TH SERVICES
7
I'niversity Press
job Siuisf'aciiDn.
•alih Professions
-ator. Rockville.
mute Inc. June.
• ies and Private
Licensure and Other
Mechanisms for Regulating
Allied Health Personnel
: Hut. Provider
•- common perirses: A case of
eds analysis in
•i Post. Health.
rnal
'hlv
troubles some
rses. Jamaica.
.il Therapists,
'dria. \'a.
ns. M o n t h l v
sonnel. Re• sicians' beTechnologv
Hospital As. New York
dical School
jvember.
an Medical
19(4):431-
to this committee directed it to "investigate current practices under which each tvpe of allied health personnel
obtains licenses, credentials, and accreditation" (Appendix A, Section
223[b][3]). The committee has taken a rather broad view of this charge,
interpreting it to encompass the whole array of mechanisms meant to
ensure that allied health personnel are properly trained and competent to
practice. These mechanisms, which include licensure and other forms of
governmental regulation, voluntary certification, and standards imposed
bv health care providers and payers, are central to this study in that thev
interact with and influence virtually all of the other study issues.
For example, the scope of practice for a Field that is defined under state
licensing statutes and regulations affects the demand for allied health personnel by constraining how they may be used by employers. Certification,
if it is accepted as a valid distinction by employers or if it is required by
accrediting bodies such as the Joint Commission on Accreditation of Healthcare Organizations, also affects employers' decisions to employ allied health
personnel: certified and noncertified members of the same allied health
field are then treated as separate labor pools. Regulatory mechanisms also
influence supply by defining who may enter and remain in cenain allied
health fields.
A great deal is at stake here. Health care payers rely on licensure and
other credentialing mechanisms to assist them in defining eligibilitv for
coverage and reimbursement for allied health services. The various allied
health occupations look to these mechanisms to give them identity and
legitimacy by defining the nature and length of training, requirements for
"'HE CONGRESSIONAL CHARGE
235
�236
ALLIED HEALTH SERVICES
entry imo the field, and the power to control certain health care pracuces.
In a lime of great ferment in health care, these control mechanisms take
on even greater significance. The proliferation of health care occupations,
changing models of health care delivery, and new reimbursement methods,
along with cost-control efforts by industrv and government, place stresses
on these controls.
To carry out this part of the congressional charge, the committee held
discussions with officials of government agencies and private organizations
responsible for the various control mechanisms. It also held a public hearing
at which 26 allied health associations and 4 experts presented testimonv;
two of the experts prepared papers for the committee on state regulation
of health occupations. In addition, the committee reviewed the research
literature on occupational regulation.
/
METHODS OF CONTROL
I
I
/
J
State Regulation
Society applies many quality control methods to health care personnel,
including allied health personnel. The states bear the greater responsibility
in this control system. Through occupational licensure and other forms of
regulation, states exercise their authority to protect the health, safetv. and
welfare of their citizens. The earliest attempts to regulate health occupations
in this country were in colonial Virginia (1639), Massachusetts (1649), and
New York (1665), when medical practice acts were enacted. Bv the beginning of the twentieth centurv, the Supreme Court had validated this use
of the states' police powers, and most states had licensed lawyers, dentists,
pharmacists, physicians, and teachers. Between 1900 and 1919. most states
also licensed nurses, optometrists, osteopaths, podiatrists, and veterinarians
(Carpenter, 1987). Before 1960, this list had expanded to include dental
hvgienists, practical nurses, and physical therapists. Since 1960, only three
health occupations have come to be universally licensed: psychology, nursing home administration, and emergency medical technology. The latter
two were licensed as the result of federal legislation.
Table 7-1 shows the licensure status of the 10 allied health fields on
which this study concentrates as of June 1987. Among these fields, physical
therapists and dental hygienists are licensed in every state. Emergency
medical technicians must be cenified by some agency in every state. At the
other extreme is medical record administration, for which no state requires
licensure; this field relies instead on certification (registration) by the American Medical Records Association. All the other fields are licensed in some
states: for example, respiratory therapists are licensed in 7 states, audiologists and speech-language pathologists in 37.
�•
e praciices.
anisms take
xxupations.
nt methods,
lace stresses
imittee held
•rganizaiions
iblic hearing
d lestimony;
e regulation
the research
i e personnel,
responsibilitv
iher forms of
h. safetv, and
h occunations
RECL LATISG ALLIED HEALTH PERSO.WEL
TABLE 7-1
237
Licensure Status of Selected Allied Health Fields
Field
Licensure Status
Clinical laboratory
tech nology
Denial hvgienc
Medical technologists are licensed in 5 states and New York
Cit\. Technicians are not licensed in any state.
Dental hvgienists are licensed in all 50 states and the District ot
Columbia. Dental assistants are not licensed in any state.
Dieticians are licensed in 14 states, the District ol'Columbia,
and Puerto Rico.
Dietetics
Emergencv medical
services
Medical record
sen ices
Occupational therapv
Cenified in all 50 states.
Neither medical record administrators nor medical record
technicians are licensed in j n v state.
Occupational therapists are licensed in 34 stales, the District of
Columbia, and Puerto Rico. Occupational therapv assistants
are not regulated in anv state.
Phvsical therapists are licensed in all 50 states. Phvsical therapv
Phvsical therapv
assistants are licensed in 18 states.
Radiographers are licensed in 17 states and Puerto Rico.
Radiology
Radiation therapv technologists are licensed in 15 states and
Puerto Rico. Nuclear medicine technologists are licensed in
10 states and Puerto Rico.
Respiratorv therapists are licensed in 7 states.
Respiratory therapv
Speech-language pathologists and audiologists are licensed in
Speech-language
36 states and Puerto Rico.
pathology/audiologv
SOURCE: Information from professional associations, updated to June 1987.
is i ^ ^ ^ i n d
BvflBindat^W^s use
.vers, dentists.
19. most states
1 veiennarians
mdude dental
*0. onlv three
dtology, nursV The latter
Geids on
«*4k.ph«ical
A t
l h e
Licensure is the most restrictive form of state regulation. Carpenter
(1987) defines licensure as "a process by which a governmental agency
restricts entry into an occupation by defining a set of functions and activities
constituting a 'scope of practice,' grants permission to engage in that practice only to persons meeting predetermined qualifications, and establishes
structures and procedures for screening applicants and granting licenses
to practice." These and other definitions share certain common elements,
including:
• licensure is intended to protect the public;
• licensure is exclusionary;
• licensure prescribes the characteristics and qualifications of persons
who may be licensed;
• licensure defines a scope of practice for licensees (and therefore licensure laws are often referred to as "practice acts"); and
• licensure prohibits nonlicensed persons from engaging in the defined
scope of practice.
Although the standard definiuons focus on initial entry, licensure also
addresses standards of practice and ethical and business behavior (what it
�238
ALLIED HEALTH SERVICES
takes to keep a license) and causes for disciplinary action (what it takes to
lose a license).
By long tradition, licensure has been, for all practical purposes, a form
of state-sponsored self-regulation because it has been carried out b\ boards
composed of members of the regulated occupation empowered to act with
a high degree of autonomy. As Shimberg (1984) noted in recounting the
history of state licensure:
These boards had broad powers to implement the lau by promiilgaiing rules and
regulations governing practice standards and professional conduct: establishing
minimum education, training, and experience qualifications; examining candidates
as to their fitness to practice: investigating complaints against practitioners; and
taking appropriate disciplinary action, including suspension or revocation of a
practitioner's license where appropriate.
1
s
t
Recent reforms have broadened the membership of licensure boards to
include representatives of the public who mav or mav not have voting
privileges. Yet. on the whole, the licensed occupations still are largely selfregulated. This point is elaborated later in this chapter. Howev er, licensure
carries vvith it a whole array of regulations and administrative procedures
for implementing the state statutes.
States can and do use a number of modes of occupational regulation
other than licensure (Table 7-2). Among the 10 allied health fields covered
in this report, title protection through registration or certification bv the
state is the most frequently used form of regulation other than licensure.
This regulatory mechanism is also applied in other fields such as accountancy, in which anyone can practice but only those who have met state
standards can use the title "'certified public accountant." In one form or
another, about 800 occupations are regulated bv the states, including architects, real estate brokers, barbers and cosmetologists, electricians, and
engineers.
Besides occupational regulation, states also oversee allied health personnel through the regulation of institutions and settings in which thev work.
Requirements for the licensure of hospitals and nursing homes include
personnel standards. In addition, states have other laws and regulations of
broad applicability in place, such as those that govern business practices
and provide consumer protection, that may be used against incompetent
or unscrupulous allied health personnel. The states also define qualifications for civil service positions held by these personnel.
Consumers may use the tort system in anv state to file civil suits to seek
compensation for malpractice by allied health personnel. Presumably, this
mechanism carries some deterrent effect: in the context of quality assurance, however, it must be viewed as a last resort.
�U-LIEb HEALTH SERYIC.ES
. action (what it takes to
a ^ a c t i c a l purposes, a form
' has been earned out IH b,;ards
•upatton
.
e m p o u
noted
e r e d
m
[
o
a
a
REGi'LATISG ALLIED HEALTH PERSO.WEL
TABLE 7-2
1. PRACTICE
u i [ h
«»v bv pronutlgating rules and
l>' "fe.ss,onal antdnct: establish^,,
i
'•"^""'"^^'""""^cindida^
'Plaints agamst p r a c t , t ,
•K suspension or revocation of a
n e r s :
i l n d
2.
b e ,
s h i
' P of licensure boards to
y or may not have vottnu
cupations still are largek | f
chapter. However, iicensure
'>d administrative procedures
?
s e
C
3.
RF.C.ts i RATION
STATUTORY CERTiric.vrio\
With state standards and stale enforcement
Through regulation, occupational members can be required to meet certain state
standards: onlv those who meet these predetermined qualifications may legallv use
the designated title of the occupation. This mode entails standards, testing, codes of
practice, possible inspections, and enforcement.
With pnvate standards and assessment and state enforcement
Through regulation, an agency of the state may require members of an occupational
group to meet certain standards established by a private testing or assessment center
or organization (reviewed by the state), with the state handling the certification and
any enforcement required. Legallv. the state is responsible for the standards set and
for monitoring the process.
t
'^ersee allied health personsettings in which thev work
nd nursing homes include
^ r laws and regulations of
govern business practices
used against incompetent
tates aiso define qualificasonnel.
'te to file civil suits to seek
•ersonnel. Presumably, this
e context of quality assur-
STANDARDS
VV'i'fAotit standards
Through regulation, a state agency can require persons in an occupation to register
and supplv certain information without requiring anv standards, testing, or
enforcement.
With standards
It is also possible to have a registration requirement in combination with minimum
practice standards that are set by a designated agency. Although registration would
not be exclusionarv. it would subject registrants to minimum standards and therebv
provide some protecrion to the public.
m i ,
•s of occupational regulation
10 allied health fields covered
'ation or certification bv the
Nation other than licensure
otherfields such as accoun> ^ M p - h o have met state
•
^ ^ W " In one form or
bv^Wstates. including arnetologists. electricians,'and
Modes of Occupational Regulation
Wiihout special enfurrfirit'nt
Through the adoption of statutes and rules, this mode can establish restrictions on
the practice of an occupation wiih civil or criminal penalties enforceable through die
courts. This tvpe of regulation requires no inspections, registration, or special
enforcement staff. Rather, it relies on action by the harmed parties or
a consumer
affairs office.
Wifh special rriforcement
Through statutes, or rules, or both, this mode can establish restrictions on the
practice of an occupation in addition to establishing inspections, enforcement
mechanisms, and penalties. However, this mode does not requite registration,
certification, or any assessment of the practitioner's credentials or competencv.
reaMtntm- the
I (
239
4.
STATUTORY CERTIFICATION AND PRACTICE STANDARDS
A state may establish, by rule, certification for an occupation and also request the
legislature to pass a law that would establish practice standards for that same
occupation. This combination would establish a svstem of title control for those
meeting certain required standards of competency, as well as establishing standards
of practice for anyone who practices the occupation.
5.
REGULATION
THROUGH
SUPERVISION
BY AN ALREADY
LICENSED
PRACTITIONER
Certification with standards
Through statutes and rules, an occupation can be certified and required to work,
under the supervision of an already licensed occupation: standards for practice can
also be established.
Continued
�ALLIED HEALTH SERVICES
240
TABLE 7-2
Continued
Through slandnrch of practice but •a ithout certification
It is also possible to regulate by providing that the occupation be performed under
the supervision of a licensed professional with certain standards set forth but without
requiring thai the individual be certified.
6.
LICENSURE
Licensure is the most restrictive form of occupational regulation, providing for both
title control and an exclusive area of practice, h requires standards of practice,
education, knowledge or minimum competencv, and inspection and enforcement
with civil and criminal penalties.
SOURCE: Goldman and Helms 11983).
Cnticisms of State Regulation
Occupational regulation has been in ferment for at least 20 \ears. Criticisms have come from a number of quarters, and these criticisms have
given rise to recommendations for reform. Some changes have occurred
as a consequence.
In the 1960s the source of concern was access to health care. With an
apparent shortage of physicians, there was concern that restrictive licensing
laws were hampering the effective deplovment and utilization of phvsicians'
assistants and other physician extenders. This issue was addressed bv the
National Advisory Commission on Health Manpower in its 1967 report.
At the direction of Congress in the Health Training Improv ement Act of
1970, the U.S. Department of Health, Education, and Welfare's Office of
the Assistant Secretarv for Health and Scientific Affairs investigated problems in health care personnel licensure and certification. The department's
1971 Report on Licensure and Related Health Personnel Credentialing
contained far-reaching recommendations, including a recommendation to
the states for "a two-year moratorium on the enactment of legislation that
would establish new categories of health personnel with statutorily-defined
scopes of functions." The moratorium was to allow time for further consideration of the tasks and functions of new health care occupations.
Questions about the wisdom of occupational licensure still remair* although the circumstances today are different. The perceived shortage of
doctors and dentists has changed to a perceived surplus, and the number
of newly emerging health care occupations is increasing. Since the early
1970s the issue of rising health care costs has taken on greater and greater
importance. In the context of cost containment, the fact that more and
more health occupations have been seeking statutorily protected scopes of
practice is worrisome. This proliferation is seen as contributing to inefficiencies in the health care industry, especially in view of the rapidity of
technological change.
�ALLIED HEALTH SERVICES
le
i
• ^^tion
be performed under
•Ttam standards set forth b,,, , ,
w
l h
' " ^ [ r ^ u h u o n . prov.dmu for bo,h
'•equires s andjrd of pracute.
•"id inspection and enfo
rcement
1
s
"ent for at least 20 vears. Critters, and these criticisms have
Some changes have occurred
access to health care. With an
'Jncern that restrictive licensing
ntand utilization of phvsicians'
his issue was addressed bv the
•Manpower in its 1967 report.
Tratning Improvement Act of
ation. and Welfare's Office of
•tific Affairs investigated prob^ ^ - The department's
^ | ^ ™ n e l Credentialing
'
^ r recommendation to
e enactment of legislation that
>onnel with statutorilv-defmed
to allow time for further conhealth care occupations,
mal licensure still remain, alt. The perceived shortage of
• ed surplus, and the number
is mcreasing. Since the earlv
taken on greater and greater
ient. the fact that more and
tatutorily protected scopes of
-een as contributing to ineffiHy in view of the rapiditv of
;
e
r
o
e
n
s o n
c
l
i
a
M
RECLLATISG ALLIED HEALTH
PERSOSSEL
241
Allied health personnel are affected by this tension. Many of the allied
health fields are new. and. according to the example offered bv older, wellestablished fields such as medicine, nursing, and dentistry, state licensure
is crucial to their achieving recognition as professions. Licensure, it is believed, gives legal validation to the field's unique status. It provides a way
of excluding unqualified practitioners from providing services; it gives
official recognition to the field's scope of practice; and it offers easily verified credentials that can be used bv employers and health care pavers
(McCready. 1982). Licensure is also considered to be necessarv to avoid
being subject to prosecution. For example, phvsicians would be v ulnerable
to prosecution for practicing medicine without a license, since many medical
practice acts are so broad that phvsicians are granted virtually unlimited
scopes of practice.
Above all. state regulation is viewed as a means of improving the quality
of health care bv restricting entrv into health care occupations to persons
who have proper credentials and by disciplining persons who do not meet
standards of professional behavior. Much of the criticism leveled at regulation is based on the lack of evidence on this point.
Cnticisms of Structure and Process
The traditional regulatory structures and processes, which were developed in the last century, are criticized as anachronistic and inconsistent
with the public policy objective of protection of the public.
By long tradition, the regulation of a health occupation, given a practice
statute, is the responsibilitv of a board. The composition of the board is
usually defined in the statute. One of the strongest criticisms of the regulatory structure is that these boards are not sufficiently accountable to the
larger public. Until recently, they were composed entirely of members of
the regulated occupation, drawn from the membership of their related
associations. In many states, they generated their own revenues by charging
fees to candidates and licensees; they had their own staffs; they were often
located in the home of the board's secretary; and they had considerable
rule-making authority with litde or no oversight. Their proceedings were
closed to the public, as were their records.
By statute, the regulatory boards are charged with setting entry requirements, practice standards, and codes of conduct, and with disciplining
licensees who fail to meet those standards and codes. The performance of
these functions has also been subject to criticism.
Eligibility standards are defined in terms of educauon and. in some cases,
experience. Boards also require entrants to pass an examination that, in
some cases, is devised bv the board. In other cases, the board relies on a
a
�242
ALLIED HEALTH SERVICES
national examination or commissions a testing organization to develop a
state exam. Criticisms that have been leveled at entry requirements are that
thev are inflexible, offering onlv one path to entry: that education and
experience requirements are unrelated to the demands of practice: that
educational requirements rest heavily on accreditation, which in turn is
controlled by the professional associations; that examinations are not valid
reflections of "real-world" practice requirements; and that the common
practice of "grandfathering" current practitioners when licensing a new
occupation is inconsistent with the goals of protecting the public health and
welfare.
"Standards of practice" are defined in terms of behav iors that are subject
to disciplinary action, including fraud and deception in obtaining the license; conviction of a felony; engaging in unacceptable patient care through
deliberate or negligent acts: knowing v iolation of the practice act; continuing to practice although unfit; and lewd or immoral conduct in the delivery
of serv ices. "Codes of conduct" most commonly prohibit business practices
that are considered unacceptable professional behav ior. Traditionally, these
have included advertising; practice in chain or department stores, shopping
centers, or other commercial environments; and engaging in competitive
bidding.
Disciplinary procedures are usually defined in the statute. In some states
and for some occupations, revocation of a license is the onlv sanction
provided. In others, the statute defines an arrav of sanctions of varying
degree, including license suspension, censure, and reprimand.
Boards have been criticized for the way they carry out their disciplinary
responsibilities: they only investigate complaints of incompetence or impropriety, rather than performing any independent monitoring. Impropriety (i.e., violation of the code of ethics) is more frequently the basis for
disciplinary action than is incompetence. The number of disciplinary actions is extremely low in comparison with estimates of the incidence of
incompetent practice. The public is not informed of disciplinary actions
against licensees. A partial explanation for the historical lack of disciplinary
vigor is the inadequacy of the resources available to the task of investigating
and "prosecuting" complaints. Without sufficient staff and budget, the
regulatory process is more bark than bite.
" T u r f monitoring and turf protection occupy a significant portion of
the energies of a state's regulatory apparatus. The various occupations
batde among themselves over which pam of health care and which parts
of the patient fall under their jurisdiction. These battles are fought bv
establishing practice acts and by implementing rules and regulations. Yet
this is not the only theater of conflict; insurance coverage and reimbursement constitute another. Yet the regulatory arena is where the identity and
power of allied health personnel are largely determined.
Rl
of
g'
1
fr:
ta;
th
�HEALTH
SERVICES
; organization io develop a
entry requirements are that
entrv: that education and
demands of practice: that
editation, which in turn is
examinations are not valid
us; and that the common
lers when licensing a new
.-cting the public health and
>f behaviors that are subject
eption in obtaining the liptable patient care through
of the practice act; continoral conduct in the delivery
prohibit business practices
havior. Traditionally, these
•partment stores, shopping
d engaging in competitive
the statute. In some states
ense is the onlv sanction
^ ^ i c t i o n s of vary ing
"d^^Biand.
• ' ^ ^ ^ m their disciplinary
s of incompetence or imident monitoring. Improre frequently the basis for
lumber of disciplinary acnates of the incidence of
•id of disciplinary actions
torical lack of disciplinary
o the task of investigating
it staff and budget, the
1V
• a significant portion of
The various occupations
ilth care and which parts
;se battles are fought bv
ules and regulations. Yet
coverage and reimburseis where the identitv and
rmined.
REGI LATISC, ALLIED HEALTH PERSO.WEL
243
In earning out this studv the committee encountered manv examples
of jurisdictional struggles among allied health and other occupations, struggles that caused their roles to be constantly shifting. For instance.
• ophthalmic medical assistants versus optometrists on performing refractions:
• surgical technologists versus nurses on who should perform various
tasks in the operating room;
• orthopdsts versus physical therapists on fitting braces and other orthotic devices; and
• audiologists versus hearing aid dispensers in hearing testing.
These struggles, in which one occupation seeks to expand its realm of
control at the expense of another, are a constant element of regulating
health services through licensure. In manv cases the issue is which occupation is entitled to perform a specific function. In others, the issue is which
occupation or occupations have jurisdiction over some portion of the human anatomv. In still others the issue is under what conditions persons in
an occupation perform their functions.. For example, in manv states, physician referral is required for physical therapy or occupational therapv but
not for speech therapv. Another important condition of practice is the level
of supervision required. These referral and supervision provisions in licensure statutes define the degree of autonomy of health care workers on
the one hand and their degree of availability to consumers on the other.
Decisions on these issues by state legislators and regulatory bureaucracies
affect the costs, quality, and accessibility of health care services.
The great difficulty facing state decision makers is that the impact on
costs, quality, and accessibility of any proposed modification in a health
occupation's scope of practice, referral, or supervision is rarely clear. The
risks and benefits of change are often hypothetical, difficult to measure,
and subject to large differences in judgment. Rhetoric and political power
frequently substitute for evidence and rational decision making. Rarelv are
rigorous studies done.
One of the clearest examples of this problem is the case of dental hvgiene
services. In the course of testimony by representatives of the American
Dental Hygienists' Association (1987a,b) and the American Dental Association (1987) before the committee, committee members learned of the
continuing controversy over the required levels of supervision of dental
hygienists by dentists.
In general, dental hygienists are only permitted to practice (i.e.. perform
a variety of chiefly preventive services—e.g., cleaning teeth, taking x rays,
applying topical fluorides, and teaching proper dental hvgiene) under the
supervision of a licensed dentist. The supervision may be "general," which
means that a dentist mav delegate a given function. The dentist must be
�244
ALLIED HEALTH SERVICES
responsible for its successful performance but does not have to be physically
present while the delegated function is carried out. Alternatively, the supervision may be "direct," meaning that the dentist must be present in the
same room as the hygienist, or "indirect," which requires only that the
dentist be present in the treatment facility.
Supervision requirements vary among the states. According to the American Dental Hygienists' Association (1987b), 38 states permit dental hygienists to practice at least some preventive oral health services under
general supervision. In some states, general supervision is limited to hospitals, nursing homes, adult day care centers, and other institutional settings. In Washington State, dental hygienists have practiced unsupervised
in long-term care facilities since 1984.
The American Dental Association is seeking to tighten supervisory requirements for hygienists. In 1986 the association's House of Delegates
passed a resolution opposing general supervision and urging state dental
societies to eliminate it from state practice acts. The same resolution urged
that, in instances in which general supervision could not be removed from
the statute, the regulations be changed to require that:
a. any patient treated by a dental hygienist first become a "patient of
record" of a licensed dentist;
b. dental hygiene services be given prior authorization by a dentist no
more than 45 days before the services are provided; and
c. the dentist examines the padent within a reasonable time after the
dental hygiene services are provided.
The justification for this resolution was that general supervision endangers the dental health of the public. Its effect would be to increase dentists'
control of dental hygiene services.
Since the resolution was passed, efforts have been made in several states
to delete general supervision. A bill to this effect was introduced in Connecticut in 1987. In Texas, where general supervision has been permitted
for over 30 years, the Board of Dental Examiners proposed rules that
would require direct supervision of all dental hygiene functions (American
Dental Hygienists' Association, 1987b). The Virginia Dental Board, which
had been on the verge of liberalizing supervision requirements, decided
against such action.
Other states are moving to relax their supervision requirements so that
dental hygiene services can be provided without the denust's physical presence. Legislation to this effect has been proposed in Missouri, Ohio, South
Carolina, and Wisconsin. At the extreme on this conunuum is Colorado,
which in 1986 became the first state to allow dental hygienists to provide
most of their basic functions without supervision by a dentist. Other functions, which are designated as "supervised dental hygiene," require a den-
�ALLIED HEALTH SERVICES
es not have to be phvsicalJy
out. AlternativeJv. the suust must be present in the
ch requires only that the
s. According to the Amerstates permit dental hval health services under
-rvision is limited to hos'd other institutional sete practiced unsupervised
> tighten supervisory rem's House of Delegates
and urging state dental
e same resolution urged
^ ^ removed from
!
d
t become a -'patient of
ization by a dentist no
1; and
sonable time after the
al supervision endan> to increase dentists'
e
made in several states
is introduced in Conn has been permitted
proposed rules that
functions (American
Dental Board, which
•quirements, decided
requirements so that
-ntist's physical presTissouri, Ohio, South
tinuum is Colorado,
v
'•s to provide
d ^ f e )>ther funct
' n t ^ ^ H j i»re a den-
REGULATING ALLIED HEALTH PERSONNEL
245
tist's supervision. Diagnosis, treatment planning, and prescription of
therapeutic measures continue to be the responsibility of dentists. The
statute imposes disciplinary action on dental hygienists who fail to refer
patients to a dentist when the treatment needed is beyond their scope of
practice. A lawsuit to overturn the statute failed but is under appeal.
In California. 15 dental hygienists are allowed to clean and examine
teeth without the supervision of dentists. This demonstration program is
one of the state-sponsored Health Manpower Pilot Projects, under which
the requirements of state practice acts may be waived for experiments with
innovative methods of health care delivery. According to the California
Office of Statewide Health Planning and Development (1987), the agencyresponsible for the program, it "is authorized to approve locally conceived
and implemented demonstration projects to prepare and utilize health
personnel for new or expanded roles."
To qualify for the program, hygienists needed at least 4 years of clinical
experience, certificauon in cardiopulmonary resuscitation, and special training
in instrumentation. They are currendy providing services in offices and in
other settings such as nursing homes. Some make house calls to people
who are bedridden. Their case records are reviewed by a dentist.
The California Dental Association sued to halt the program on the basis
that it was a threat to public health and that the procedures followed by
the state and by California State University in approving and implementing
the program were inadequate. In August 1987 Judge Rothwell B. Mason
of the Sacramento County Superior Court ruled against the dental association. His opinion was that the program was consistent with the legislature's intent to enable experimentation with new kinds and combinauons
of delivery systems and the need for exemptions from the healing arts
practice act to permit such experimentauon (California Dental Association v.
Office of Statewide Health Planning and Development et al., Proceedings, August
28, 1987, California Superior Court, County of Sacramento).
In neither the Colorado nor the Califomia cases were the substanuve
issues resolved; both cases, to date at least, have hinged on procedural
matters. In neither case were any data or research findings presented to
suppon arguments about risks or benefits. In addidon, no evidence was
presented on the issue of what dental hygienists' training includes and what
types of responsibilities hygienists are prepared for, on the issue of accessibility of services, or on the costs of services.
In its testimony to this committee the American Dental Association (1987)
stated that it "believes that all segments of the public should receive the
same high standard of dental care." The associadon expressed its concerns
about the great responsibility placed on dental care providers by the need
to diagnose nondental diseases that manifest symptoms in the mouth and
the need to provide services to padents who are severely medically compromised (American Dental Associadon, 1987).
�246
ALLIED HEALTH SERVICES
The committee questioned the American Dental Association spokesperson about those circumstances, such as practices in public schools, in which
it would be beneficial to allow hygienists to provide prophylactic services
to children who had been examined bv a dentist but without the dentist
being present. The association's official position is that this form of delivery
is not acceptable (Institute of Medicine, Committee to Studv the Role of
Allied Health Personnel, 1987).
The situation in dentistry is not unique. It illustrates issues of cost, quality,
and access to health care services that are common to manv health care
fields. The committee is concerned that such issues are faced by the courts,
state legislatures, and regulatory agencies with neither a body of statistical
evidence nor the informed judgments of knowledgable, disinterested parties available for guidance. Without such information, there is considerable
risk that decisions will be made on purely political and economic grounds.
Cnticisms as to Outcome
In addition to criucisms of the structures and processes of state regulation, there have been substantial criticisms of the outcomes of regulation
• in terms of health care cost, quality, and accessibility. A bodv of research
literature generally calls into question whether state regulation as we know
it is serving the public. The literature shows with some consistency that the
costs (prices) of health care services and products (e.g., eyeglasses, dentures)
are higher in states with more stringent regulation (Begun, 1981; Gaumer,
1984). The incomes of health professionals are also higher in states that
restrict the activities of their substitutes and auxiliaries.
Higher consumer prices presumably reduce access to health care by
keeping some consumers out of the market entirely. There is also direct
evidence that restrictions—for instance, on practice setting—may reduce
the quantity of services provided. Begun (1981), for example, found that
optometrists practicing in chain oudets conducted more eye examinations
in a day than optometrists in private offices. Many states prohibit practice
in chain oudets.
The effects of restricuons on quality of care are less clear, largely because
of the great difficulty in obtaining data with which to assess quality. This
is unfortunate, because quality is central to the policy debate over the extent
and nature of occupauonal regulation. The various health occupations
argue for instituting regulations, for changing their scope of practice, and
for limiting the scopes of other occupations entirely on the grounds of
quality of care.
As Begun (1981) points out, in this context, "quality" is ill-defined: "it
may refer to the degree of respect for the professional, the degree of
communication or humanism in the professional-client relation, the technical sophistication of the service, or the actual outcome of the service."
REGU-*
Other p
the degi
client sai
Howe
For exai
have su;
the othe
�' HEALTH SERVICES
REGILATISC
iociation spokesperlic schools, in which
•rophylactic services
without the dentist
his form of delivery
> Studv the Role of
Other possibilities include the professional's number of vears of training,
the degree of trust the client has for the professional, and the degree of
client satisfaction.
However quality is measured, its relationship to regulation is equivocal.
For example, studies by Maurizi (1974) and bv Carroll and Gaston (1977)
have suggested that quality is actually lower with greater regulation. On
the other hand, Holen's (1977) studv of dentistry showed that more stringent state licensing standards reduced the probability of adverse outcomes.
Gaumer (1984) concluded from a review of the literature that state regulation could not be shown to reduce the risk of health care personnel
making mistakes or errors in judgment, nor in general ensure competence.
Begun (1981) showed that restrictions on optometric practice are associated
with higher quality, higher cost, and lower accessibility. Yet quality was
measured in terms of duration of eve examinations and their complexity,
so the result might be attributable to fewer "low-quality" exams being done
rather than to more "high-qualitv" exams.
Criticisms of the outcomes of state regulation are also aimed at its effect
on geographic and career mobility. There is considerable research to suggest that state licensure, especially vvith limited reciprocity, limits the geographic mobility of licensed personnel. It also limits career mobility by
prohibiting advancement from one level to another and by prohibiting
occupational change without additional education. The difficulty of transferring credits and of obtaining credit for skills acquired on the job means
that "initial career choices create a pathway which can be left only by tracing
one or more steps backward and essentially starting from an entry level
once more" (Carpenter, 1987).
•sues of cost, quality.
J manv health care
faced by the courts.
a bodv of statistical
disinterested parhere is considerable
economic grounds.
e
$ s ^ ^ » t a t e regu^^Hregulation
A b o l ^ f research
elation as we knowconsistency that the
•veglasses. dentures)
, un, 1981; Gaumer.
ligher in states that
:on
r
to health care bv
here is also direct
[ting—mav reduce
sample, found that
e eve examinations
es prohibit practice
ear. largely- because
assess quality. This
oate over the extent
health occupations
pe of practice, and
3n the grounds of
" is ill-defined: "it
ial, the degree of
the tech^ ^ ^ ^ m service."
r
ALLIED HEALTH
PERSOSSEL
247
Reforms of State Regulation
Twenty years of criticism have led to a number of recommendations for
the reform of state regulation of health occupations, some of which have
been implemented.
Criteria for Regulation: "Sunnse" Procedures In the face of a growing
number of occupations seeking licensure and a growing concern about the
cost-effectiveness of licensure. 13 states have sought to bring a greater
degree of reason and due process to what had been largely an ad hoc and
political procedure. Minnesota was the first state to enact sunrise legislation
in 1973. The Minnesota example, criteria from the Council of State Governments, and principles emanating from the U.S. Department of Health,
Education, and Welfare have been used as guidelines in these efforts.
The criteria in general have been similar. Basically, they consist of a set
of guidelines to use in deciding whether an occupation should be regulated
and another set for deciding on the most appropriate form of regulation.
�248
ALLIED HEALTH SERVICES
Criteria for regulating an occupation include evidence of harm from
unregulated practice, evidence that the occupauon involves specialized skills,
and evidence that the public is not protected by any other means. More
recently, a criterion of cost-effectiveness has been added by some states.
Minnesota's statute and current regulations (see Appendix F) are an example of these criteria. The rules spell out in some detail what constitutes
evidence of harm, including the kinds of harm that are recognized and
how to assess the potential for harm, and the extent of danger inherent
in the occupation's functions.
Minnesota's regulations also appropriately recognize the rather long list
of "other means" for protecting the public: supervision by other practitioners, state or federal laws governing devices and substances, employment
in licensed facilities, federal licensing or other requirements, civil service
procedures, or national certification procedures. A consideration of these
other means not only guides the initial decision to regulate at all but can
also guide the design of the appropriate regulatory mechanism when one
is-needed.
The criteria for selecting the mode of regulation follow the principle of
using the least restrictive activities consistent with public protection (see
Subdivision 3 of the Minnesota statute, Appendix F). The least regulatory
mode is the strengthening of the base for civil acuon or criminal prohibitions, or both. This is essentially a reliance on the deterrent effect of
potential civil actions or criminal penalues. The most regulatory mode is
occupational licensure, which prohibits persons who do not meet the state
standards from engaging in practice. An intermediate mode is the establishment of title protection through registration or cerufication.
Certification has been used for many years in the field of accountancy.
Accountants are certified by the states after meeung certain eligibility criteria. These criteria vary among the states, but all states require passing
grades in each of four parts of the uniform national examination given by
the American Institute of Certified Public Accountants (CPAs). Some states
have education requirements; some also require experience in public accountancy. Certified status allows an accountant to offer independent judgment about an organization's financial records, the value of its assets, and
so forth. In general, large organizations have their financial accounts audited and evaluated by CPAs. A lender generally requires an audited statement from a firm seeking a loan. The Securities and Exchange Commission
requires an audited statement before approving a stock offering. In these
capacities, CPAs wield considerable influence, their expertise is widely understood and respected, and they can command substantial salaries.
On the other hand, a person can prepare a firm's financial statements,
complete tax returns, and perform most accounting funcuons without being
certified. Unless a company wants to borrow money or sell shares to the
public, it does not have to pay for the services of a CPA. An individual
REGUL
�HEALTH SERVICES
REGULATISG ALLIED HEALTH PERSONS EL
ice of harm from
is specialized skills,
ther means. More
-d by some states,
'dix F) are an exil uhat constitutes
e recognized and
' danger inherent
taxpayer is not required to have his or her tax return prepared by a CPA.
Thus, there are lower cost opdons available for a wide variety of accounting
services. Using these lower cost and presumably lower quality options is
not without risk; an individual might be fined by the Internal Revenue
Service or see his or her company fail because of poor accounting services.
However, in this field, consumers are able to weigh the risks and benefits
and to choose among an array of providers, based on the importance they
place on certification and their financial constraints.
The concept of economic impact is relatively new in this arena. It makes
explicit a concern that the imposition of regulation, whatever its benefits,
carries with it certain costs to society. These include any increases in the
cost or price of services, insurance premium costs, the costs of additional
training, and the costs of operating the regulatory mechanism itself. In
some states, these regulatory operating costs are defrayed wholly or in part
through licensing fees and thus . not get charged to the consumer. In
evaluating the regulatory burden, however, these costs are significant, irrespective of how they are financed. There is probably merit in having
them made public, even if they are paid through licensing fees, as a means
of focusing attention on how^ much regulation costs society.
An economic impact statement requirement is very useful. It could and
should be expanded to a broader "environmental impact" statement to
incorporate other criteria such as access and quality into the considerations.
This broader statement would encourage allied health occupations seeking
sute regulation, other parties at interest, and the states themselves to make
as explicit as possible the nature of the trade-offs under considerauon.
he rather long list
i by other practinces, employment
ients, civil service
i d c ^ ^ i of these
' ^ ^ B l but can
h a i ^ ^ ^ hen one
a
" the principle of
ic protection (see
e least regulatory
T criminal prohi:terrent effect of
^ulatory mode is
ot meet the state
ode is the estab-ation.
of accountancv.
-ain eligibility cri> require passing
nination given bv
PAs). Some states
nee in public acidependentjudgof its assets, and
cial accounts auan audited statemge Commission
'ffering. In these
tise i ' -•'delv unwl ^ ^ k ,
"^^^Bments,
'ns ^TOut being
«11 shares to the
V. An individual
249
Reforms of the Regulatory Structure and Process
The criticisms enumerated above have led to calls that date back to the
late 1960s for structural and procedural changes. These recommendauons
for change have been aimed at increasing the public accountability, efficiency, and effecuveness of state regulatory boards.
Board Composition Widening the membership of regulatory boards has
been one of the most consistent recommendations made by criucs of state
occupauonal regulation (e.g.. Public Health Service, 1977; Begun, 1981;
Cohen, 1980; Shimberg, 1982). As stated by Tuohy (1976, cited in Begun,
1981. p. 94), "Governments cannot continue to expect that coherent public
policy can be achieved by dealing with professional groups as if they were
the "owners' of their respective technologies." The need for public input
has generally been associated with consumer involvement, that is, the inclusion of one or more "lay" members on each licensure board. A number
of states have taken this step. These lay members generally are consumers
�250
ALLIED HEALTH SERVICES
(much of the impetus for having them came from the consumer movement): they may or may not have full membership status—voting priv ileges,
for example.
Although informed consumers have a great deal to offer to the regulatory process, there is some question about whether the addition of 1 or
2 consumers to a board with 8 or 10 members of a regulated field, especially
if the consumers cannot vote, will have the desired effect of making the
board more accountable to the public. More far-reaching recommendations
to this end include:
• Drawing the "public" board members from the appropriate sute agencv.
Bureaucrats would have the advantage of (1) technical knowledge relevant
to the task, and (2) a power base from which to exert leverage on other
board members. The power would flow from the agencv head and, ultimately, the governor (Cohen, 1980).
• Drawing a majority of the board members from outside the regulated
occupation. A far cry from one or two "token" consumers, under this
proposal boards would be dominated by lay members (Begun. 1981).
• Drawing board members entirely from persons outside the regulated
occupation. Board members could be not only consumers but others with
relevant expertise in such fields as education, public health, economics,
health administration, and health services research (Cohen, 1980).
In the last case, the board could employ as consultants either individuals
or a panel of technical advisors drawn from the regulated field. However,
because no member of the board would come from the field and because
board members would have considerable relevant expertise of their own,
they would be likely to avoid "capture" or domination by the field and its
association(s).
Location of Boards in tlie State Administrative Structure A second major
recommendation to improve accountability has been to strengthen the
connections between regulatory boards and one or more state agencies.
One approach has been to centralize the administrative support, including
recordkeeping, the investigauve staff, and other common funcuons of boards
in a single state agency, either the health department or a special department established for this function.
Another approach, recommended by Selden (1970), is to have a single
board that regulates all health occupations and that is linked to a state
agencv that provides all administrative, analytical, and investigative support.
Subcommittees from each field would develop policies for that field, subject
to approval by the full board.
A third approach is to link related health occupations through joint
boards. Rather than the single board envisioned by Selden, there would
REGL'I
be a ni
occupy.
board
Stru.
desirah
occupa
and pr
profess
double
dentist
�\U '^/t.AI
TH
EK\l(.t;s
S
unsumer move>ting pn\ ileges.
:
:
eal to offer to the re^u'>e>- the addition of f
'fgtdated field, especiallv
•ed effect of makinsr the
•chmg recomrnendatK^ns
f
o
a
PP''opriate state agencv
•"cal knouledge relevant
exert leverage on other
• -'gencv head and. ulti"» outside the regulated
consumers, under this
>ers (Begun. 1981).
> outside the regulated
s
'timers but others with
'Wic health, economics
(Cohen, 1980).
•tants either individuals
plated field. However
thejjeld and because
^ ^ k
their own
' ^ P field and its
r
RECLLATISG ALLIED HEALTH
PERSOSSEL
251
be a numberof boards but considerably fewer than the number of regulated
occupations. Virginia is mov ing in this direction with a proposal for a joint
board for several allied health occupations.
Structural changes in the direction of greater accountability are highly
desirable. To be fully effective, however, thev should apply to all health
occupations, not just to those thai are the newest. States will need to examine
and probablv revise their practice acts for phvsicians and other health care
professionals and to rev iew the structures of regulation for those fields. A
double standard, one applicable to allied heallh fields and one to medicine,
dentistry, and nursing, is not desirable.
Infonnation for tlie Public The regulatory process has been criticized for
being conducted v irtually inv isibly. Not only has doing business in a closed
fashion been a barrier to public accountabilitv, it has kept the regulatory
process from serving an important educational function. Through state
regulation the public could become much better informed about the different health care occupations, their credentials, and the services thev offer.
Public education could also increase state citizens' awareness of the importance of occupational regulation. Such awareness would be likelv to
elicit greater interest and participation.
No single model for accountability is obviously superior to all others.
Each state should use its own mechanisms consistent with the objective of
cost-effective public protection.
11
e x
1
0
o
i
r
f " " A second major
-en to strengthen the
r more state agencies,
^e support, including
on functions of boards
't or a special departO). is to have a single
t is linked to a state
'nvestigative support
• for that field, subject
s
1
Rations through joint
Selden, there would
The Federal Role
The federal government plays a very important role in regulating allied
health personnel. Although it does not regulate health occupations directly,
it has indirect influence on state regulatory policy by supporting evaluation
research, sponsoring policy analyses, and fostering information dissemination. It has direct responsibility for setting standards for eligible providers
under Medicare, however, and a shared responsibility with the states for
standard setting under the Medicaid program. Medicare conditions of
participation, which apply to all institutional providers of health services,
are a powerful regulatory tool because providers that do not meet the
conditions may not receive payment from the program except in emergency
circumstances. These regulations can be used to define the qualifications
of allied health personnel working in panicipating hospitals, nursing homes,
and other health care institutions.
The federal influence is also exerted by the actions of the Federal Trade
Commission. The commission has conducted and sponsored research on
the effects of regulation and has struck down certain anticompetitive practices of regulatory boards such as prohibitions on advertising.
�252
ALLIED HEALTH SERVICES
The federal government has taken an important leadership role in health
occupations regulation. Reports issued bv the U.S. Department of Health,
Education, and Welfare in the 1970s were influential in drawing attention
to problems in the mechanisms of state regulation. Recommendations from
those reports and from studies sponsored by the Labor Department helped
shape the new directions in state regulation.
The Bureau of Health Professions has supported studies of occupational
roles that are useful in devising entry and practice standards. The bureau
has also helped develop and disseminate information on state regulatoryactivities through its support of the Clearinghouse on Licensure, Enforcement, and Regulation of the Council of State Governments.
In addition, the bureau has supported the National Commission for
Health Certifying Agencies (NCHCA), a body that sets standards for organizations that certify allied health personnel. NCHCA sets standards that
are designed to ensure that certifying agencies are accountable to individuals seeking certification, to their employers, to health care payers, and to
the public. (A copy of their standards is attached as Appendix G.)
The federal Medicare program has a significant impact on allied health
personnel through the way it defines covered services. By means of regulation, the secretary of the Department of Health and Human Services
cap define the qualificauons (e.g.. licensure) of personnel providing services
such as physical therapy, occupauonal therapy, and speech therapy.
Private Control Mechanisms
Private recognition of competence also offers some assurance to the
public; it may take several forms. Membership in an association is an indicadon that an individual has met certain standards for admission. The
standards may include qualifications of educadon or experience, moral
character, and so on. In a number of allied health fields, a basic requirement
of membership is graduauon from an educauon program approved by
CAHEA. Dental hygiene programs are accredited by the American Dental
Associadon. Physical therapy education programs are accredited by the
American Physical Therapy Association.
Certificadon by a private agency or association generally imposes more
rigorous standards than those required for association membership. Certificauon has been defined as:
. . . the process by which a nongovernmental agency or association grants recognition to an individual who has met certain predetermined qualifications specified
by that agency or association. Such qualifications may include graduation from an
accredited or approved training program, acceptable performance on a qualifying
examination, and/or completion of some specified amount or type of work experience. (Shimberg, 1984)
REGULA
In a pa[.
tification
v idual a
"register
be used
case.) T:
except ti
bv perse
Histoi
whereas
higher >
board v\
This di?
attests u
Two :
anisms .
health p
which a
institute
certain
tional 3'
professi
gram" (
' The :
for allit
homes
ganizat
ificatioi
health
�HEALTH SERVICES
idership role in health
Apartment of Health,
I in drawing attention
commendations from
>r Department helped
udies of occupational
mdards. The bureau
i on state regulatory
' Licensure, Enforcements.
nal Commission for
?ts standards for orA sets standards that
•ountable to individcare pavers, and to
ppendix G.)
3act on allied health
* Bvmeans of reg•
Serv ices
l d
?1
f - ^ ^ g services
eech therapy.
e assurance to the
issociation is an inor admission. The
experience, moral
basic requirement
ram approved by
American Dental
accredited by the
ally imposes more
membership. Ceriation grants recog"lifications specified
graduation from an
nee on a qualifying
tv pe of work expe-
RECULAT1SC ALLIED HEALTH
PERSOSSEL
253
In a paper prepared for this committee. Carpenter (1987) notes that certification establishes "standards of competence" and then grants an individual a certificate allowing them to use an occupational title, for example,
"registered dietician." ("Registered" is a very confusing term because it mav
be used to mean licensed, as with registered nurses, or certified, as in this
case.) This mechanism is, of course, analogous to certification by a state,
except that it does not include legal prohibition against the use of the title
bv persons not meeting the standards.
Historicallv, licensure has been concerned with minimum competencv,
whereas certification has been reserved for those meeting considerably
higher standards. In medicine, for example, certification by a speciality
board was (and is) viewed as a "badge of excellence" (Shimberg, 1984).
This distinction is less clear-cut today, when in some fields certification
attests to basic entry standards and in others it attests to special achievement.
Two forms of private accreditation are used as quality assurance mechanisms for allied health personnel. In the context of credentialing allied
health personnel, accreditation most commonly refers to a process through
which a private association or agency "grants public recognition to a school,
institute, college, university, or specialized program of study having met
certain established qualifications or standards" (Shimberg, 1984). Educational accreditation is a form of peer review that is meant "to provide a
professional judgment of the quality of the educational institution or program" (Committee on Allied Health Education and Accreditation, 1987).
The second form of accreditation that is a quality control mechanism
for allied health personnel is the accreditation of hospitals and nursing
homes by the Joint Commission on the Accreditation of Health Care Organizations. The joint commission promulgates standards that include qualifications of key hospital personnel. Many of these standards apply to allied
health personnel (see Table 7-3).
CONCLUSIONS AND RECOMMENDATIONS
In light of potential future shortages of allied health personnel and the
need to find a reasonable balance between health care costs and quality,
the committee believes that it is important to maintain flexibility in the use
of existing personnel and a variety of routes of entry for new personnel.
It appears that widespread use of licensure carries with it higher costs
to consumers, reduced access to health care services, and reduced flexibility
for managers. People in health care careers are inhibited from changing
fields and from advancing within their fields by rigid requirements imposed
by state regulatory mechanisms. Although these control mechanisms are
designed and carried out in the stated interest of protecting the health and
welfare of the public, their effectiveness in this regard has been mixed at
best.
jt
�254
ALLIED HEALTH
SERVICES
TABLE 7-3 Joint Commission on Accreditation of Healthcare
Organizations' Accreditation Standards for Hospitals
Field
Summarv of Relevant Standards (if am )
Clinical laboratorv
technology
The director is a member of the medical staff and preferably a
board-certified pathologist. There are sufficient qualified
laboratorv technologists and supportive staff to perform the
required tests. A qualified technologist is a graduate of an
approved medical technology program or has equivalent
education, training, and/or experience, meets current legal
requirements of licensure/registration; and is currently
competent.
Dietetics
A qualified dietitian dispenses the nutritional aspects nf patien;
care and ensures that quality nutritional care is provided to
palients.
Medical records
A hospital must employ or have as a consultant a registered
record administrator or an accredited record technician T
consultants onlv are used, medical record supervisors are to
demonstrate competence.
Phvsical therapv
See rehabilitation services.
Occupational therapv
See rehabilitation services.
Radiology
The director of the radiology service is to determine the
qualifications and competence of department personnel: at
least one qualified radiologic technologist is available: a
technologist does not independently perform diagnostic
fluoroscopy except under certain circumstances.
The director of the nuclear medicine service is to deiermine
the qualifications and competence of department personnel
who are not independent practitioners.
"U'hen radiation oncology procedures are performed in the
hospital, designated qualified technologists are assigned as
needed."
Rehabilitation services Each individual providing physical rehabilitation services must
meet relevant licensure, certification, or registration
requirements. Separate services are defined, including
occupational iherapv. physical therapy, prosthetic and
orthotic services, psychological services, recreation therapv.
social work services, speech-language pathology or audiology
services, and vocational rehabilitation services. No specific
staffing standards are given bevond the general one.
Separate standards require lhat comprehensive rehabilitation
services be provided "in an interdisciplinary manner." and
that the qualitv and appropriateness of these services be
monitored and evaluated.
r
�HEALTH SERVICES
REGILATISC, ALLIED HEALTH PERSOSSEL
ealthcare
TABLE 7-3
255
Continued
Field
Respiratory therapy
alf and preferably a
Hicient qualified
•talf to perform the
• a graduate of an
'" lias equivalent
neets current legal
id ts currentls
ial aspects of patient
tare is provided to
lant a registered
orcj technician, i f
' supervisors are to
eiermine the
ient personnel: at
is available: a
>rni diagnostic
tances.
• is to deiermine
• iment personnel
rformed in the
are assigned as
non services must
egisiration
-d. including
osthetic and
•creation therapv,
hology or audiology
ices. No specific
eneral one.
nsive rehabilitation
rv manner." and
ese services be
Summary of Relevant Standards (if anv)
Respiratory care services are to be provided bv a sufficient
number of qualified persons under competent medical
direction. If warranted, services are supervised by a technical
director registered or cenified by the National Board for
Respiratory Therapv. Inc. Other qualified personnel mav
provide services commensurate with their training,
experience, and competence: these include registered
respiraiory therapists or certified technicians; persons with
equivalent education or experience; qualified
cardiopulmonary technologists: and appropriately trained
licensed nurses.
SOURCE: Accreditation Manual for Hospitals (1988).
Statutory cerufication, w hich legallv reserves the use of a title to persons
with specific qualifications, affords most of the benefits of licensure and
avoids many of the costs. In conjunction with public education, it gives
consumers the opportunity to choose among providers knowledgeably. It
does not prevent consumers from choosing lower quality or lower cost
alternatives. It permits institutional employers some flexibility in their staffing. It permits innovation—new careers may provide new cost-effective
methods of diagnosis and treatment.
The committee recommends statutory certificadon for fields in which
the state determines there is a need for regulation because this form of
regulation offers most of the benefits of licensure with fewer of its costs.
Medicare and other third-party payers should accept state tide certification as a prerequisite for reimbursement eligibility. Such certification
can and should be based on examinations and other eligibility criteria
the states may establish.
The committee endorses the establishment of sunrise criteria to guide
states' decisions about whether to regulate health occupations and, if so,
how. These decisions should follow three basic principles:
1. the protection of the public is the sole reason for states to regulate
health occupations;
2. the least restrictive regulatory mechanism consistent with public protection should be selected, taking into account other means that are in
place; and
3. if, after due deliberation, the decision is made to regulate an occupation, it must be followed by a continuing commitment of resources on
the part of the legislature, the governor, and the relevant administrative
agencies.
�256
ALLIED HEALTH SERVICES
State regulatory structures and procedures must be improved if they are
to be effective. In most states the composition of boards, the requirements
for entry, and the flow of information to the public are not fully consistent
with the public interest.
The committee recommends that states strengthen the accountability
and broaden the public base of their regulatory mechanisms. In the near
term, the committee suggests the following:
• Licensing boards should draw at least half of their membership from
outside the licensed occupation; members should be drawn from the
public as well as from a variety of areas of expertise such as health
administradon, economics, consumer affairs, education, and health services research.
• Flexibility in licensure statutes should be maintained to the greatest
extent possible without undue risk of harm to the public. This may mean,
for instance, allowing multiple paths to licensure or overlapping scopes
of practice for some licensed occupations.
The regulatory process should be conducted as openly as possible and
should produce a flow of information to the public, including:
• the scope of practice of the occupation as defined by state law and
regulation;
• the eligibility requirements for entry into the occupation;
• basic information about licensees, including the status of their license
and any disciplinary actions taken by the state, as well as basic data such
as educational background, which should be collected as part of the licensing process; and
• board membership and procedures, especially procedures for filing
complaints against licensed professionals.
Regulatory boards should be well connected to the state bureaucracy.
If a state requires graduation from an accredited educational program
for licensure, the state should take an active interest in the accreditation
requirements to ensure that they are consistent with the state's interests.
Finally, the committee believes that decisions by states, accrediting bodies,
and health care payers regarding scope of practice, referral, and supervision should be better informed. The Bureau of Health Professions (or
another future focal point for allied health personnel in the Department
of Health and Human Services) should sponsor a body with members
drawn from allied health and other health professions and from the health
and social science research communities to assess objectively the evidence bearing on jurisdictional issues. This body, in consultation with
other experts and interested parties, should consider issues of risk, cost.
�I ED HEALTH SERVICES
> improved if they are
e
irds. the requirements
ire not fully consistent
en the accountability
:hanisms. In the near
eir membership from
be drawn from the
rtise such as health
tion, and health serained to the greatest
)lic. This may mean,
overlapping scopes
^flPoS:
n]
^PFossible and
icludihg:
rludihsr:
id by state law and
ipation;
itus of their license
as basic data such
as part of the licedures for filing
• bureaucracy,
ucational program
i the accreditation
state's interests,
iccrediting bodies,
ferral, and superh Professions (or
i the Department
ly with members
d from the health
iectively the evionsubation with
"e?
k, cost,
R E C L L A T I S G ALLIED H E A L T H P E R S O S S E L
257
quality, and access. It should draw on available scientific evidence and
identify topics on which research is needed.
Well-designed experiments and demonstrations of innovative roles for
allied health personnel will provide valuable evidence to guide regulatorypolicy.
REFERENCES
Accreditation Manual for Hospitals. 1988. Chicago: Joint Commission on Accreditation
of Healthcare Organizations.
American Dental Association. 1987. Testimony before the IOM Committee to Study the
Role of Allied Health Personnel's Hearing on Regulation. National Academy of Sciences. Washington. D.C. July.
American Dental Hygienists' Association. 1987a. Paper submitted to the IOM Committee
to Studv the Role of Allied Health Personnel's Hearing on Regulation. National Academv of Sciences. Washington. D.C. July.
American Dental Hygienists' Association. 1987b. Testimonv before the IOM Committee
to Study the Role of Allied Health Personnel's Hearing on Regulation. National Academy of Sciences. Washington, D.C.July.
Begun, J. W. 1981. Professionalism and the Public Interest: Price and Quality in Optometry. Cambridge, Mass.: M I T Press.
California Office of Statewide Health Planning and Development. 1987. Health Manpow er
Pilot Projects Program: Annual Report to the Legislature and ihe Healing Arts Licensing Boards. Sacramento: State of California Office of Statewide Health Planning
and Development.
Carpenter, E. S. 1987. State regulation of allied health personnel trends and emerging
issues. Background paper commissioned by the Institute of Medicine Comminee to
Study the Role of Allied Health Personnel. National Academv of Sciences, Washington,
DC.'
Carroll, S. L., and R.J. Gaston. 1977. Occupational Licensing: Final Report. Washington,
D.C: National Science Foundation.
Cohen, H. S. 1980. On professional power and conflict of interest: Stale licensing boards
on trial. Journal of Health Politics, Policy and Law 5(2):291-308.
Committee on Allied Health Education and Accreditation. 1987. Allied Heallh Education
Directory, 1987. 15th ed. Chicago: American Medical Association.
Gaumer. G. L. 1984. Regulating health professionals: A review of the empirical literature.
Milbank Memorial Fund Quarterly/Health and Society 62(3):380-416.
Goldman. S. K.. and W. D. Helms. 1983. The regulation of the health professions. A
policy review prepared for the Commission of Health Regulatory Boards of the Commonwealth of Virginia. Richmond, Va. October.
Holen, A. S. 1977. The Economics of Dental Licensing. Arlington. Va.: Center for Naval
Analysis.
Institute of Medicine, Committee to Study the Role of Allied Health Personnel. 1987.
Mechanisms for Conlrolling the Quality of Allied Health Personnel. Public hearing
held on July 1 at the National Academy of Sciences, Washington, D C.
Maurizi, A. 1974. Occupational licensing and the public interest. Journal of Political Economy 82:399-413.
McCready. L. A. 1982. Emerging health care occupations: The system under siege. HCM
Review (Fall):71-76.
�258
ALLIED HEALTH
SERVICES
National Advisory Commission on Health Manpower. 1967. A Report by the Committee
on Health Manpower. Vol. 1. Washington. D.C: Government Printing Office.
Shimberg. B. 1982. Occupational Licensing: A Public Perspective. Princeton. N.J.: Educational Testing Service.
Shimberg. B. 1984. The relationship among accreditation, certification and licensure.
Federa] Bulletin (Aprirj:99-1 15.
CS. Department of Heahh. Education, and Welfare. Office of the Assistant Secretary for
Heallh and Scientific Affairs. 1971. Report on Licensure and Related Heahh Personnel
Credentialing. Washington. D.C. Government Printing Office
r
�T H PROFESSIONS
EDUCATION FOR T H E FUTURE:
SCHOOLS IN SERVICE T O T H E NATION
R e p o r t o f t h e P e w H e a l t h Professions C o m m i s s i o n
F e b r u a r y
1 9 9 3
�L
PEW HEALTH PROFESSIONS COMMISSION
Co-Chairmen
David R. Clare
Former President
Johnson & Johnson
William C. Richardson, PhD
Franklyn G. Jenifer, PhD
President, Howard University
Jean Johnson-Pawlson, MSN, NP-C
Associate Professor
Department ofHealth Care Sciences
The George Washington University
President, The Johns Hopkins University
Commission Members
Jacqueline Bolden Beck, EdD
Dean and Professor
School of Allied Health Sciences
Florida A and M University
Ronald E. Beller, PhD
Vice President for Finance
lona College
F. Peter Libassi
Senior Vice President
The Travelers
Myron S. Magen, DO
Walter F. Patenge Professor
Community Health Sciences
Dean Emeritus
Michigan State University
The Honorable Jim McDermott, MD
United States House of Representatives
Lester M. Crawford, DVM, PhD
Executive Vice President for Scientific Affairs
National Food Processors Association
James J. Mongan, MD
The Honorable John C. Danforth
United States Senate
Arnold S. Relman, MD
Professor of Medicine and Social Medicine
Harvard Medical School
Editor-in-Chief Emeritus
The New England Journal of Medicine
Rheba de Tomyay, EdD
Dean Emeritus, School of Nursing
University of Washington
John A. DiBiaggio, DDS
President, Tufts University
Allan J. Formicola, DDS, MS
Dean, School of Dental and Oral Surgery
Columbia University
Jere E. Goyan, PhD
Dean, School of Pharmacy
University of California-San Francisco
Robert Graham, M D
Executive Vice President
American Academy of Family Physicians
Dean, UMKC School of Medicine
Executive Direaor, Truman Medical Center
David E. Rogers, MD
The Walsh McDermott
University Professor of Medicine
Cornell University Medical Center
Sheila A. Ryan, PhD
Dean, School of Nursing
University of Rochester
Leonard D. Schaeffer
Chairman and CEO
Blue Cross of California
Ralph Snyderman, M D
Chancellor for Health Affairs
Dean of Medical School
Duke University Medical Center
John R. Hogness, MD
Professor ofHealth Services
President Emeritus
University of Washington
James R. Tallon
Karen M. Ignagni
Samuel O. Thier, MD
President, Brandeis University
Direaor, Employee Benefits
AFL-CIO
Majority Leader, New York State Assembly
Neal A. Vanselow, M D
Chancellor, Tulane Medical Center
�ABLE OF C O N T E N T S
Foreword
1
The Challenges to Education
5
Health Care in Crisis
The Future of Health Care
Praaitioners for a Different Future
Barriers to Change
Opponunity in Adversity
Leadership Challenges
13
Recommendations
Policy Recommendations
23
Federal
State
Professional Associations
Higher Education
Summary of Strategies for Health Professions Schools
27
The Allied Health Professions
35
The Dental Profession
47
The Health Care Administration Profession
57
The Medical Profession
71
The Nursing Profession
83
The Pharmacy Profession
93
The Public Health Profession
101
The Veterinary Profession
109
Acknowledgements
120
III
SchooL in Service to the Nation
��T H E A L L I E D H E A L T H PROFESSIONS
Comprising more than 60 percent of the entire health care work force, and spanning over
200 distinct disciplinary groups, allied health is the largest and most complex health professions
constituency in the United States. Defined broadly, allied health includes all of the health-related
disciplines, with the exception of nursing and the so-called MODVOPP disciplines: medicine, osteopathy, dentistry, veterinary medicine, optometry, pharmacy,
and podiatry. The allied health work force includes more than
" A l t h o i i v h the divCVthree million health professionals who provide services in a
^
o
range of settings, including hospitals, clinics, physicians'
sity thut dlUed
health
offices, hospices, extended-care facilities, health maintenance
organizations, communis programs, and schools. Allied
represents
SeweS OS UH
health professionals share responsibility for the deliver}' of
CtdvUfltClQe i f l Cldhealth care services, including: prevention, identification,
1 1 1 1
monitoring and evaluation of diseases, disabilities, and disorUVeSSlTlg t h e n e d l t n
ders; health promotion; rehabilitation; health systems manage^
^ / / ^ ^
^
ment; and dietary and nutritional services.
<
>
When confronted with the complexity that is allied
Cthedd, thlS
diversity
health, the Institute of Medicine-National Academy of
/
J
' J '4X1
/
Sciences Committee to Study the Role of Allied Health
it
dlJpCUlt
Personnel declared that there was litde consensus as to which
•foYqg
fi
hvOCldlv
disciplines constitute allied health. Because more comprehen1 1
7
7
sive definitions of allied health make study of all allied health
shared Understanding
difficult, the IOM committee chose to focus study on 10 large,
o f allied health "
well-known and relatively unstudied allied health professions:
J
clinical laboratory technology, dental hygiene, dietetics, emergency medical personnel, medical records administration, occupational therapy, physical therapy,
radiologic technology, respiratory therapy, and speech-language pathology/audiology. The IOM
committee concluded that current shortages in many of these disciplines may indeed worsen, and
they emphasized the imponance of acting now to avoid major crises in the availability of some allied health services.
Although, as mentioned, the diversity that allied health represents serves as an advantage in
addressing the health care challenges that lie ahead, this diversity has made it difficult to forge a
broadly shared understanding of allied health. Yet such understanding is essential in national, regional, state, and local health policy processes that, at present, proceed incrementally and typically
only under the spur of well-defined crises. For instance, there has been litde, if any, policv response to the well-documented shortages of key allied health professionals, shortages that are predicted to worsen. Although allied health comprises more than 60 percent of the entire health care
work force, federal spending targeted for allied health totaled a scant $ 1.6 million in fiscal year
1991, or less than 1/300,000 of total federal health spending.
Personnel shortages and understaifing in hospitals and other health services settings, inadequate funding for educational programs, faculty shortages, limited scholarship assistance in educational institutions, and the inability to recruit and retain personnel in underserved areas all
dramatize the potential for a real health manpower crisis for society. Already facing severe personnel shortages, allied health will find its ability to respond challenged by the demands of an
aging society, the AIDS crisis, the health promotion and disease prevention movement, and the
growth of home care and chronic care for people of all ages with disabilities.
#
h
a
s
35
Schools in Service to the Nation
�Allied Health Education
Allied healrh education occurs at a variety of levels and settings. Educational levels range
from the awarding of certificates for training at vocational schools or nonhospital health services
facilities, to postdoctoral training at major academic health centers. Institutional providers of
training include two- and four-year colleges, universities located both in and out of academic
health centers, vocational/technical schools, hospitals, and other health services facilities.
A sense of the broad scope of allied health education is provided by Table 1, which displays
the programs accredited by the Committee on Allied Health Education and Accreditation
(CAHEA) of the American Medical Association. Although not all allied health education programs are included, CAHEA accredited more than 2,800 programs that enrolled more than
83,000 students in 1,525 institutions during the academic year 1989-90. Overall, schools of allied
health at two- and four-year technical schools, colleges and universities house over 2,000 allied
health educational programs and graduate more than 40,000 professionals each year. Graduates of
programs in the allied health sciences account for as many as one out of every six graduates from
institutions of higher learning listed by the U.S. Department of Education. Thesefiguresdo not
include the numerous and important hospital-based allied health education programs.
Among allied health disciplines, degrees are awarded at the associate, baccalaureate, and graduate levels. Ar the two-year level, the most common degree awarded is the associate in applied
science (A.A.S.). Two-year programs provide graduates with not only skills that can be immedi-
T A B L E
,1
SUMMARY OF CAHEA-ACCREDITED PROGRAMS
ACADEMIC YEAR 1989-1990*
INSTITUTIONAL TYPE
PROGRAMS
ENROII MENTS
Academic health
center/medical school
321 ( 11.3%)
10,255 ( 12.3%)
89 (5.8%)
389 ( 13.7%)
17,100 (20.5%)
228 ( 15.0%)
946 (33.3%)
30,003 (35.9%)
417 (27.3% )
Vocational or technical
college
286 ( 10.1%)
14,574 ( 17.4%)
177 (11.6%)
Hospital or medical
center
824 (29.0%)
8,956 (10.6%)
556 ( 36.5%)
Nonhospital health
care facility
37 (1.3%)
369 (0.4%)
35 (2.3%)
Veterans
Administration
20 (0.7%)
177 (0.2%)
12 (0.8%)
Depanmeni of Defense
22 (0.8%)
Four-year college or
university
Junior or community
college
TOTALS
2,845
2,139
(2.6%)
83,573
INSTITUTIONS
11 (0.7%)
1,525
The Comminee on Allied Health Education and Accreditation (CAHEA) of the American Medical Association accredits most
but not all allied health education programs. Thus, while this table provides a general sense of the breakdown of enrollment by
institutional type, tt does not reflect total enrollment across all programs.
36
Pru- Healtl' ProfeainTU Cnmrritsiion
�ately applied in the labor market but also a foundation for additional education. General education courses are combined with discipline-specific didactic, laboratory, and practicum experiences.
Baccalaureate education in allied healrh is as diverse as the occupations and professions within
the field. Generally, however, some combination of liberal arts and sciences courses, professional
courses, simulated laboratory experiences, and real or simulated clinical experiences is required to
attain the degree. In addition, general education or core courses common to most allied health
disciplines are usually included in the educational experience.
Historically, allied health professionals have earned graduate degrees in relatedfields,such as
education, health care administration, or a basic science. More recently, rapidly expanding knowledge bases and evolving professional responsibilities have led to the development of graduate programs specific to allied health disciplines at both the master's and doctoral levels. Programs found
at the master's level are either for professional entry or advanced study beyond the entry-level
credential, with emphasis in such areas as research and clinical expertise.
Emerging Trends in Allied Health
Changing Demography
Among the demographic and social trends emerging in the United States, the aging society,
the post—baby boom decline in traditional-age students, the increasing numbers of women and
minority work force entrants, the changing ethnic and racial mix, and changes in the family unit
will have particular impact on allied health. The aging of the nation's society and the accompanying shift: to chronic care that is already occurring foretell major shifts in care need in which allied health professionals are major providers of services. The
continuing decline in high school graduates, a result of the
"All'
J 1
11
£
"baby bust" that started in the mid-1960s, and the steadily
AlUed
health
profesincreasing dropout rate have created a reduction in the appliStOTials
P f e d o f f l t n a t e 171
cant pool for the health professions. This has a particularly
* ^
hard impact on allied health, where current shortages of
COmmUnity-based
trained professionals are expected to worsen as the gap besettlWS
and are
keV
tween demand and supply widens. Meeting future health
o
J
service demands will require both recruitment of older and
p l a y CVS i n W e l l n e s s a n d
returning students and education for reentry of midcareer
. .
„
health professionals. To the extent possible, linking the varprevention.
ious occupations into career ladders would also assist greatly
in meeting this demand. Allied health professionals are predominantly women, a reflection of the
lowered barriers to access to a health profession provided by allied health training at hospitals and
two-year colleges. This has also been true for large numbers of ethnic and racial minorities, who
are better represented in allied health than in other health professions. Nonetheless, their numbers
are not adequate, particularly at the higher education levels, and much remains to be done to increase their representation.
Great amounts of informal care are rendered each year, mostly by relatives and friends. At
a time when need is skyrocketing, the sources of this care are declining and are threatened by the
aging of older caregivers, decreasing average family size, and the high divorce rate. The volume
of needed assistance is projected to increase at least 50 percent each decade from now until the
year 2050. Absence of a willing and able caregiver is a major reason for admission to and continued stay in a nursing home. As evolving care needs exceed caregiver availabilirv, alternative
types of formal service increasingly will be needed to substitute for informal care, the current cost
of which is estimated to be between $16 billion and $24 billion. Allied health professionals will
play important roles in this increased use of formal services and will also carry weighty responsibilities for the education of home care aides, family, and friends of care recipients.
37
Schools in Srrvicc to the Nation
�Changing Panems of Disease
The increasing prevalence of chronic disease is requiring more allied health personnel. Allied
health personnel possess the training and skills to work in service settings for the chronically ill,
settings that require a better understanding of the personal, social, and environmental factors underlying disease prevention, rehabilitation, and long-term care. Furthermore, the massive deinstitutionalization of persons with mental disabilities from 1950 to 1980 has increased their ranks in
chronic care settings and in the home and will have other troubling consequences as these individuals aging parental caregivers are less able to carry out such efforts. Secondary schools are now required to adapt their environments and their personnel to meet the special needs of people with
disabilities. Allied health professionals such as occupational, physical, and speech-language therapists play key roles in maintaining persons with disabilities in chronic care, home, and school settings.
Refocusing on Health Promotion
Preventable illness and injury claim more than one million lives and cost society more than
$450 billion every year. Recent estimates reflect that roughly 60 percent of deaths are premature
and that about 60 percent of all illness and disability are preventable. The promulgation of the
Health Objectives for the Nation in 1979, the newly released goals for the year 2000 by the U.S.
Department ofHealth and Human Services, and the more
"TV/* /
JJ' '
7
recent use of the Health Objectives for strategic planning by
With adaitlOnal
p i Health Service all signal a major federal emphasis
truiniflQ' Provided
P
" - The best locations for wellness activities are
. . .
. .
those that are most accessible to the community needing ser
Within existing
vices: worbites, schools, and aging centers. Allied health pro
ti-rnrrrsim c s i l l i v s l
fessionals predominate in community-based settings and are
<*
key players in wellness and prevention. 1 heir participation
h e u l t h profeSSionuls
^ ^y increase in the future by virtue of both the locations
i l l
.
of their praaices and the content of their skills.
t h e
u b
o n
reven
i c
on
ov
could play a major
part
in addressing
the
Advancing Medical Information and Technology
The information technology explosion and the growth
V e x i n g p r o b l e m s OJ
of health informatics and expert systems affect allied health in
aCCeSS tO h e a l t h
several ways. First, allied health is a major contributor to these
growth areas through such disciplines as health information
Services i n r u r a l
management, which is making imponant progress in the
/ .
.
n
development of a paperless medical record. Second, the movea n d i n n e r - C i t y areas.
f medical technology and instrumentation to miniaturization and portability means more high-tech care in many
dispersed settings including the home, where allied health professionals are already major providers. Third, advances in genetic engineering are giving major impetus to the need for, and
growth of, allied health programs in laboratory technology and genetic counseling. Finally, educational applications of information technology such as tele- and videoconferencing are widening access to allied health training in both rural and inner-city areas. This is especially important since
such areas are typically affected by personnel shonages and have been and are anticipated to be
most affected by future hospital closings. Improved access to services in these areas is needed now
and will only become more of a priority.
m e n t
0
38
Pru; Health Professions Commis
�Ensuring Qualit)- Care
The current and continuing focus on quality within the health care system depends on its
capacity to assess the efficacy of outcomes. This capacity needs improvement with regard to the
services provided by allied health professionals. Outcomes review will not only shape practice
guidelines but also improve awareness of allied health contributions to consumer health.
Increased attention to consumer preferences, as well as the improved awareness of consumers
themselves, will lead consumers to value those health professions that demonstrate sensitivity to
these preferences. As competition and consumerism increase, the likelihood that allied health
care alternatives will be found will also increase, since intensified competition typically forces the
search for alternative services and markets. Institutional and individual consumers increasingly
will opt for not only affordable but also high-quality services, something achievable through more
extensive employment of allied health professionals. Consumer demand for nurse midwives in the
hospital setting serves as an example of this phenomenon.
Declining Access and Growing Cost ofHealth Care
If regulatory practice barriers were reduced, allied health professionals could contribute more
toward addressing access problems, even as currently trained. With additional training provided
within existing programs, they could become a major pan of addressing the vexing problems of
access to health services in rural and inner-city areas. The unmet needs of the aging, mothers and
infants, and persons with AIDS, among others, may well pave the way for such changes. Allied
health professionals are also well positioned to respond to emerging trends in the financing and
delivery of health services. As the health services delivery system becomes more rational, selected
allied health services in alternative senings could substitute well for more expensive forms of medical and institutional care, a much-needed response to justifiable pressures for cost containment.
Delivery trends toward home- and community-based ambulatory care, primary care, long-term
care, and provider team care will all increase the demand for allied health personnel.
Strategies for Allied Health
The diversity of allied health is acknowledged, but the demands of the emerging health care
system will require more integration among and within the disciplines. Anention to defining allied health and its educational core, evaluating and accrediting allied health programs, improving
faculty development, and enhancing student recruitment and retention are indicated. There is
also an overarching need to rationalize the educational system by creating horizontal as well as vertical growth alternatives in the allied health professions. The Pew Health Professions Commission
makes the following recommendations to the allied health education community, the allied health
professions, and to policymakers at the state and federal level.
Strategy 1: Explore models for unifying parts of the allied health professions in clinical
service and education.
Description: Developing a consensus vision of allied health in the future will necessitate four interdependent actions, including collecting comprehensive educational and praaice data, conducting a strategic planning projea on the future of allied health, implementing model curricula
based on a new core with major and minor areas of study, and establishing an improved national
association for allied health educational programs.
39
Schools in Service to the Nation
�Collect Comprehensive Educational and Practice Data
Seven biennial reports to the President and Congress on the status of health personnel in the
United States have lamented the lack of accurate data for allied health. A coordinated data collection plan that addresses deficiencies in compatibility, validity, reliability, and consistency of existing data sources must be developed. Data describing supply and demand across the various
allied health disciplines are the highest priority, closely followed by information describing demographic and professional practice characteristics. A complete educational data base is also desirable. A consortium of members of educational institutions, employers, professional associations,
and state and federal agencies should identify the range of data needed and specify collection, analysis, and disseminarion methods.
f
Conduct a Strategic Planning Project on the Future of Allied Health
Socierv and the allied health professions desperately need a clearer vision of allied health, one
that is unified, empowered, understood, integrated, and goal-seeking: unified so that those in allied health perceive and support common interests; empowered so that practitioners have greater
autonomy in a suitably widening range of services; understood so that allied health professionals,
their clients, the government, the general public, and other health professionals know what can
reasonablv be expected; integrated so that allied health disciplines themselves are linked and are
,
capable of linking well with other health professions; and goal1 he edUCUtlOfl
seeking so that allied health leadership and its constituencies
of allied health
J
p r o f e s s i o n a l s s h o u l d be
j
,•
viewed as a continuum
o f phases, each o f Which
. ,
„
.
i n c l u d e s a J O T m a l COm-
petency assessment
Component.
•*
s e e k a s h a r e d s e to f s o a l s - A strate
ic
s P
lannin
ro ect w o u l d
gP j
address redefining the core curriculum, broadening disciplinary participation, linking with clinical education settings,
and fostering teamwork and curricular effectiveness. It would
llluminate
s i o n s
£
e m e r g i n g rnission o fthe
^
health profes
.
651
^ sugg specific goals derived from the mission to
serve as targets for focused efforts until 2005. It should be
undertaken by a consortium similar if not identical to that
for
data colle
™-
"
Implement Model Curricula Based on a New Core with Major
and Minor Areas ofStudy
Rather than the nearly 200 sometimes narrow and specific occupations and professions, allied
health baccalaureate degrees should be more broadly based within categories such as critical care,
administration, rehabilitation, or diagnostic science. Specificity would then be achieved via appropriate minors such as nurse anesthesia, health information systems, medical technology, or occupational therapy. The primary goal is more effective use of core curricula to achieve more general
bases of education for a group of majors and minors. One way this could be accomplished is by
using a biomedical, administrative, and social science core within the general education requirement, linked with more broadly defined areas of study, such as critical care, diagnostic science,
rehabilitation, aging, home health, prevention, or health care administration. Such programs
could also be structured to facilitate linkages with two-year college and graduate programs for
career development purposes.
Estahlish an Improved National Association for Allied Health Education Programs
The now-defunct American Society of Allied Health Professions, which attempted to represent all the individual practitioners, disciplines, professional associations, and educational programs that form allied health, has reconstituted itself a the Association of Schools of Allied Health
s
Professions, with a principal focus on representing the educational programs in hospitals, two-year
colleges, and four-year colleges and universities. With this excellent start, attainment of a highly
functional national association for allied health educational programs should now be pursued
aggressively.
40
Peu- Heahh Profession' Cowmissim:
�Rationale: The creation of a vision of what allied health will become, and thus a greater utility
for its qualities and diversity, is a major challenge confronting policymakers, the public, and allied
healrh professionals themselves. Given the current size and diversity of allied health, even health
policymakers are puzzled at the low profile and scant funding afforded the field. The public has
an even more obscure image of allied health. This identity issue extends to individual professionals themselves, many of whom see themselves not as allied health professionals but as members
of their individual disciplines. These four integrated actions should help allied health begin to
forge a clear identity through which it can strengthen all of its activities.
Better data will facilitate planning and policy-making at institutional, state and federal, and
professional levels. Improving core curricula would directly relate to the Pew Commission's
strategy of restructuring schools of allied health while fostering innovation. The continuing fragmentation of the health care services system into smaller specialty components argues forcefully
for a moratorium on the establishment of new disciplines and a concerted effort to consolidate
educational arrangements for those already in existence. Together with a consensus created
through strategic planning, a core curriculum could substantially strengthen allied health's developing identity. Finally, an educational association would be well positioned to serve as a convener
of the three major educational settings, and it would be a key player in broadening disciplines represenred in the core, in linking with clinical education settings, and in demonstrating greater educational flexibility. As schools strive to restructure, an improved national association could help
these institutions optimize the organization of faculty, the planning of continuing competency
programs, and the implementation of research.
S t r a t e g y 2: Encourage continuous validation of clinical practice in allied health.
Description: Allied health faculty is a key resource for this strategy, which has a general focus
on stronger links to improve outcomes among teaching, practice, and research.
Centers ofExcellence for Faculty Development in Research, Clinical Practice, and Teaching-Learning
Regional centers of excellence should be designed to expose allied health faculties to the best
models in research, clinical practice, and teaching. The centers should also foster innovation, assist
schools in redesigning curricula, and prepare faculty members as change agents and leaders capable
of ushering in the necessary changes in their schools and helping gain wider acceptance of allied
health in the academic community. Since the growth of various allied health disciplines will require the integration of knowledge and skills from other disciplines, centers of excellence should
use the combined strengths ofbasic medical science and allied health faculties. Such programs
should be limited in number and targeted specifically for research, clinical practice, and teachinglearning purposes.
Clinical Scholars Program
A clinical scholars program should be created to provide promising faculty members with the
opportunity to expand their research skills. Of particular relevance will be the development of the
skills needed to address health services questions, many of which must be answered if the effectiveness of currently accepted practices is to be fully known.
Continuing Competency Requirements/Programs
Schools, professional associations, and state licensing agencies should better coordinate their
commitment to and expectations for lifelong learning and continuing competency. The education
of allied health professionals should be viewed as a continuum of phases, each of which includes a
formal competency assessment component.
41
Schools in Srn'icc to the Nation
�Unification of Academic and Clinical Resources and Experiences
To achieve the goal of delivering the highest quality- teaching, research, and health services
programs, most medical education institutions have unified academic and clinical service units,
with rhe head of the academic unit typically also the head of the corresponding service unit.
Unification provides for the synthesis of teaching, service, and research, each of which is supported
and strengthened by the others. Teaching is enriched by student access to clinical content, service
is improved by the rigors of student instruction, and research productivity is enhanced by access to
patients and patient data bases. This integrated model also eliminates the traditional alienation of
clinicians from academia and of academicians from clinical practice. Such a model should be developed in allied health and tested in demonstration projects. Aspects found to be meritorious
could then be implemented on a larger scale.
Cuiricular Emphasis on Priman' Care and Prevention
The allied health professions already make numerous contributions to primary care, but
much more is possible. Selected allied health disciplines should be identified and targeted for
demonstration projects on the development of curricula focusing on the clinical and didactic aspects of primary care and prevention.
Rationale: The knowledge base relevant to what works and what does not is actually worsening as
new techniques, interventions, and procedures are brought into a current practice base that itself
has not been Rdly validated. Moreover, these rapid changes in the practice base continue to challenge the best efforts to ensure continuing competency. Mechanisms for bringing more academic
faculty into the clinic and more clinicians into the classroom would reduce the traditional alienation that academicians and clinicians experience, open the way for more clinical research, and
allow for validation of the knowledge base underpinning clinical practice. Centers of excellence
and scholars programs are two means to prepare faculty with the necessary skills for expanded roles
as academic clinicians. Also, not all institutions have the appropriate infrastructure to develop
strong programs for the optimal development of faculty. It is cost-effective to concentrate resources in a selected number of centers of excellence to ensure a positive outcome. Demographic
changes and an explosion in health informadon and information technology have transformed lifelong learning from a luxury to an imperative. Demonstrations in unifying the academic and clinical experience will be facilitated by the presence of such faculty as well as by the development of
approaches to maintain continued competency across disciplines.
S t r a t e g y 3:
Improve the linkages among allied health practitioners and within allied
health educadon.
Description: Flexible career linkages across disciplines must be created and supponed in both
educational programs and workplace settings. Furthermore, these new linkages should be
expanded across health care administration, public health, and allied health education and
practice.
Flexible Career Linkages
Employers have large pools of employees in lower-level positions, many of whom have the
ability to move up the career ladder. Existing models of cooperation and flexibility that promote
vertical and horizontal articulation should be disseminated and new models designed and tested, as
they may provide both alternatives to current entry-level pathways and new opportunities for those
already on the job.
42
1'rj' Hftilih
Profe>s:nii:
Cn'nmi.^if'r
�Linkagei Among Allied Healrh Programs
There are important missing linkages among hospital-based, two-year college, and four-year
college and university allied health educational settings. One approach to improve this state of
affairs is to develop forums for educational programs housed in these three major settings to address the human resource needs of both the public and private sectors of health services systems.
Such forums would facilitate networking and the exchange of ideas and data concerning recruitment and retention through career information, as well as the development of scholarship support
and career ladders.
Health Care Administration/Public Health/Allied Health Linkages
The community-based, behavioral, and environmental approaches inherent to most schools
of public health provide one of several possible bridges for allied health's migration from an emphasis on teniary care settings to one featuring community-based services.
Rationale: The multiple levels of training and education in allied health are poorly coordinated
across hospital-based, two-year college, four-year college and university programs. The creation of
more flexible vertical and horizontal career alternatives is needed to make optimal use of the vast
human resource pool in allied health. These alternatives are
lacking in educational programs and in the workplace. Allied
health linkages with academic neighbors in public health and
health care administration are also relatively sparse and yet
have major implications for the future of allied health.
while health care employers already make sigmhcant investments in the education of their employees, partnerships
between employers and schools would strengthen the funding
of educational programs and better meet the needs of em-
"Allied
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ployers. These linkages might also open new ways to finance
major
implications
allied health education through employer investment.
•*
Moreover, such linkages could improve coordination, cooperation, and collaboration among all institutions currently respon/
11 n
sible for educating allied health professionals. Currently, few, if
any, programs in health care administration or public health in
the United States teach their graduates about the capacity, ability, and knowledge base of allied
health graduates or about new ways to organize or utilize allied health professionals for optimal
public health and cost-effeaive health care. Because many of the nation's schools of allied health
also contain programs to prepare health care administrators, these locations could foster the Pew
Commission's interest in innovation by restructuring their programs to include more content and
process on creative utilization of human resources.
for
the future of allied
Strategy 4:
Develop, test, and evaluate new ways of utilizing allied health workers in the
care systems.
Description: The use of multiskilled or cross-trained employees in selected disciplines must
be investigated and tested. The multiskilled practitioner is an important respondent to a
number of health care issues, including cost-effectiveness, quality care, consumer satisfaaion,
professional development, and personnel shortages. To augment development of a more rational, cost-effective, and efficient system of health care services, demonstration projects
should explore different ways of allowing the allied health work force to apply their skills.
43
Schools in Srrvicc to the Nation
�Such projects could lead not to only rhe changing of currenr restrictive limits to practice manifested in narrow and highly specialized credentialing and accreditation bur also ro the fostering of substantial change and innovation.
Rationale: Use of multiskilled allied health providers could result in important cost reductions
and quality improvements. Cross-rrained health care workers, who can perform several jobs, can
assist in controlling the cost of health care and can help reverse more than two decades of creeping
specialization. Growing shorrages of health care providers will require employers ro restructure
and redefine tasks, and this presents an opportunity to address unresolved issues surrounding the
difference between new skills and new applications of existing skills.
S t r a t e g y 5: Enact institutional accreditation for allied health programs.
Description: Accreditation bodies in allied health should be encouraged to implement outcome standards compatible with the Pew Commissions competencies, streamline options for
program accreditation and identify costs and benefits of currenr accreditarion processes, and
develop a common data base on accreditation. This strategy will require leadership and willingness to change on the part of the CAHEA.
Outcome Standards for Accreditation
Accreditation processes and standards in the health professions should respond to, if not reflect, consumer needs and preferences emanating from health care system trends. More allied
health programs should monitor the outcomes of their educational activities through feedback
from employers and patients. Accreditation and credentialing should be reoriented to ensure
quality outcomes and to protect the public.
Options to Programmatic Accreditation
School-wide or academic health center-wide approaches to accreditation should be developed
for allied health. Unlike medicine, dentistry, public health, nursing, pharmacy, or veterinary
medicine, which have school-wide accrediting mechanisms, allied health programs are accredited
one by one. Therefore, large schools may face up to 15 to 25 separate program accreditations in
the course of afive-yearperiod. A study should be undertaken to identify the costs and benefits
of these multiple accreditations, identifying both their positive effects and the aspects that may
serve to constrain innovation. The study should include analysis of both direct and indirect costs.
Common Data Base on Accreditation in Allied Health
Allied health schools should convene a task force to identify the most desirable features of a
common data base containing information from multiple accreditations. A professional organization or association or an insritution should then be commissioned to create and maintain the data
base.
Rationale: Allied health is confronted with the burden of multiple accreditation processes that are
largely uncoordinated, inefficient, and as a rule, not ourcome-oriented. Thev are expensive and
are generally perceived as barriers to improvements in both curricular effectiveness and educational
flexibility. Exploration of approaches to combine accreditation activities across programmatic lines
presents an opportunity not only to reduce some of the problems of inefficiency and inconvenience, but also to promote much ofthe Pew Commission's agenda by using the opportunity to
reorient accreditation standards toward the assessment of outcomes and to include an emphasis on
44
I'cw Health profession: Camnnsiioi:
�the competencies identified by the Pew Commission. Conducting a thorough, impartial study of
the costs and benefits of the current procedure is a necessary parr of the process of change, and it,
a well as all schools and programs in allied health, would be aided by the creation of a data base
s
of accreditation information.
S t r a t e g y 6: Broaden efforts to enhance minority representation in allied health.
Description: New models developed for allied health education should be appropriate for a
diverse population with substantial minority representation. They should result in measurable improvements in minority applicant/entrant pools in allied health, and they should include early identification programs for minority students and practitioners for entry into
structured mentoring systems for clinical skills, research, and leadership.
RationaU: All indications point to maintenance of, if not an increase in, the proportion of allied
health applicants, matriculants, and graduates who are representative of minority populations. As
allied health education begins the concerted effort represented by the preceding strategies to consolidate and strengthen its educational programs, it must reach out to these students. Targeted recruitment, vertical and horizontal mobility, and early identification of minority students and
practitioners for structured mentoring experiences would increase mobility and improve the
quality of the human resource pool in allied health.
45
Schools in Smnce to the Nation
��T h e Pew Health Professions Commission
is a program of The Pew Charitable Trusts, administered through
the UCSF Center for the Health Professions. The Pew Charitable
Trusts, a national and international philanthropy with a local
commitment to Philadelphia, suppon nonprofit activities in the
areas of conservation and the environment, culture, education,
health and human services, public policy, and religion. Through
their investments, the Trusts seek to encourage individual development and personal achievement, cross-disciplinary problemsolving, and innovative, practical approaches to meeting the
changing needs of society.
I
�
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Health Care Reform
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2006-0810-F
Description
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<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
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Clinton Presidential Records
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Workforce Briefing Book [6]
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Health Care Task Force
General Files
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2006-0810-F Segment 1
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Box 49
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
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Clinton Presidential Records: White House Staff and Office Files
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42-t-2194630-20060810F-Seg1-049-008-2015
12090749