Who's minding the hospitals?

You've heard there's a shortage of nurses. That's bad. What you may not have heard is that there's a shortage of just about every other healthcare profession, that it's going to get worse before it gets better, and that it looks as if the only thing that will relieve the problem in the short run has already been done.

According to the Journal of Public Health Dentistry (September 2000), 25% of the population living in rural areas has no dentists or primary care physicians readily available. The Associated Press reports a shortage of radiologists in Massachusetts so severe that it's leading to deaths because there's a shortage of physicians who can read an x-ray accurately. MSNBC reported that by the year 2020, the United States will have a 20% shortfall of nurses. The Department of Health and Human Services reported that in 1998 there was a national shortage of 2,700 pharmacists, and this grew to 7,000 by the year 2000.

Hang on, there's more.

These needs estimates are based on population figures from the official census -- which admits to an undercount. The issue of providing a more accurate count became a political issue. The Republicans opposed statistical corrections because the uncounted people were more likely to be poor, which means they would be most likely to be Democrats. These people may not be counted now, but they'll be counted when they turn up in Emergency Rooms in a few years. In other words, as bad as the projections are, they're probably underestimates.


There's a decline in applications to nursing and pharmacy schools which is likely to make the shortage worse. Applications to medical schools remain high, probably because the salaries are still high, but physicians' job satisfaction levels are declining, and the profession isn't as attractive as it used to be. The Journal of Dental Education reports that there are 400 unfilled faculty positions in dental schools, and these vacancies will have to be filled before more dentists can be trained. Not only are we losing the healthcare professionals that we'll need in a few years, we're losing the ability to replace them. As the Baby Boom generation marches inexorably towards the age of high blood pressure, arthritic joints, reading glasses and removable dentures, it looks as if the only good advice is to take a book with you to the Doctor's office. You'll have a long wait.

Then, consider that there are an estimated 40 million Americans without health insurance of any type. These people aren't using the healthcare system unless it's absolutely essential, and that reduces the projections of need. But the uninsured, like the uncounted, are getting older, and once they qualify for Medicare, it's safe to assume they'll put even more pressure on a system that's already in disarray.

So far, we've been able to make do by shifting over some professional functions to technicians or less skilled professionals. The reason there isn't a severe shortage of physicians is that some of the functions once performed by an MD are now assigned to physicians' assistants, nurse practitioners, nurse anesthetists, and in some cases, pharmacists. Tasks that were once performed by nurses are now done by nurses' aides, and pharmacists have the assistance of pharmacy technicians. Computers have made things faster in a lot of professions, and these methods have all helped. In addition, hospitals have sent recruiters all over the world to find nurses and physicians to fill open slots in American hospitals. This has been an effective method for keeping the shortages down in the richest nation in the world, but don't ask about the impact on healthcare in other countries.

The issue gets down to money. Nobody wants to pay. Insurance companies want to make a profit, so they put the squeeze on providers -- whether that's a hospital, physician, or clinic or chain drug store. Since the insurance companies are big, they have a lot of leverage, and can threaten to take their patients someplace else. Even the biggest hospital is tiny compared with a modest insurance company. Hospitals met these pressures by cutting back on staff, freezing salaries, and generally folding up like a piece of tissue paper. In constant dollars, nursing salaries haven't changed since 1992, but the work load, based on hospital admissions, has increased by 12 to 25% since 1996. Hospitals have dealt with the nursing shortage by increasing case loads and requiring mandatory overtime. Nurses have dealt with these working conditions by finding other jobs.

There were other forces at work as well. Conservatives tend to use personal wealth as a measure of personal worth, and it didn't take long for the message to get around. In a society that measures personal worth by net worth, all at current market prices, a successful day trader is worth more than a nurse. In the past, women were restricted to the professions of nursing and education. This led to a large pool of qualified professionals, and allowed salaries to be kept low. As career opportunities expanded, women opted for better paying occupations, creating a shortage, while salaries in nursing and related fields failed to follow the laws of supply and demand. Economic planners simply assumed that healthcare professionals would be willing to work for their current salaries and wouldn't jump ship to find other occupations -- and that somehow, people who graduated college summa cum laude couldn't see that an MBA is worth more than an MD.

Hospitals, the largest employer of nurses and a major employer of other health professionals, have been starved by frozen Medicare reimbursement rates. The Bush budget does project increases in Medicare spending, but these are based on constant costs per patient and increased case loads. There is no provision for making working conditions more attractive, or luring people back into the healthcare professions. The Bush budget will give the average millionaire a savings equivalent to the annual salary of a registered nurse but offers no benefits to nurses.

Even if there were enough money available to improve working conditions and make healthcare professions more attractive, there is a time factor. It takes four years to train a nurse, six years to train a pharmacist, and seven years, plus a residency, to produce a qualified physician. Start a catch-up program now, and that's how long it will take to show any results. So far, there's no evidence of the sort of reconsideration of social values that would make the healthcare professions more desirable occupations than dealing in bonds and commodities. As long as we hold onto this sort of value system, the enrollment rates in schools offering training in health professions will continue to decline.

Right now, there's concern about whether there will be any money left in the Medicare trust fund to pay the bills as the baby boomers age. It may be even more relevant to ask if there will be anybody sending in the bills to be paid.

Sam Uretsky is a pharmacist who writes on health issues from Long Island, N.Y.

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