Where Next for Healthcare
The prospects for the professions
Howard M. Spiro '44, M.D. '47, went to medical school partly because his father and grandfather told him to. "And in the 1940s," he notes, "we listened to our elders." But the Me Generation and self-actualization have intervened since then, making career choices for many young people more of a quest for personal fulfillment, which has, perhaps, made those decisions all the more agonizingly complex. In editing The Yale Guide to Careers in Medicine and the Health Professions: Pathways to Medicine in the 21st Century, published earlier this year, Spiro and his colleagues sought to simplify that process and better inform those considering a career in healthcare. "It's clear to me that medicine is a place where many different kinds of people can work, where almost anyone can do some good," says Spiro, a gastroenterologist who spent 44 years at Yale University School of Medicine, and still sees patients twice a week. "It's a mansion with many rooms."
The book uses first-person narratives that give voice to the dramatically wide range of career opportunities: from professionals involved in direct patient care, such as doctors, nurses, social workers, dentists, and midwives, to those careers that are more often played out behind the scenes, like biomedical scientist, medical administrator, lawyer, pharmacist, ethicist, academic, and epidemiologist. As of last year, the field of "medical services" employed 12.3 million people, making it the nation's third-largest industry employer (behind trade and manufacturing), according to the Employment Policy Foundation's 2002 "American Workplace Report."
The role of healthcare in the economyuse of it, money spent on it, and people employed by itis expected only to grow, largely as a result of advances in medical technology and demographics. The role of Medicare and managed care will also influence the future job market. "The government's latest projection was that we would need 5.3 million new healthcare workers by 2010," asserts Debra Stock, vice president of member relations for the American Hospital Association (AHA) in Washington, D.C. Hospitals, many of them seeing labor shortages across the board, employ the majority of healthcare workers in the United States. "Some of the most severe shortages are in nursing, pharmacy, imaging technology, and clinical laboratory staff," she says. "You can basically pick the profession you want, and the opportunities are there."
The Employment Policy Foundation's report outlines an overall need for people trained in mathematics and engineering. Those skills are also needed in medical-related jobs requiring high-level quantitative analysis. The field of biotechnical research is a good example, explains Rakesh Shankar, a macroeconomist at Economy.com, near Philadelphia. He predicts a huge demand for "enablers""people who are trained in the medical sciences, but who are willing to do biotechnology researchto convert that technology into something practicalversus people who are familiar solely with life sciences or lab research," he says. "We just don't have enough people now working on biotechnology" applications in medicine.
In fact, the role of technology in projected healthcare growth cannot be overstated, says economist Paul Ginsburg, Ph.D. '71, founder and president of the nonpartisan Center for Studying Health System Change in Washington, D.C. Ginsburg says people need to recognize that even the magnitude of current demographic trends is small, in a sense, in relation to the impact of technology on healthcare.
"In the long term, technology is the absolute dominant driver in healthcare spendingand thus employment," he says. "Technology accounts for more than half of the growth in healthcare spending per capita over time, and it does so by offering new treatments and diagnostic procedures." Baby boomers who have trouble with their knees, he points out, can now get minimally invasive surgery that was unavailable 15 or 20 years ago. "Medical care is offering more than it did before, people benefit from it, and it costs more money," Ginsburg continues. "But whether costs are contained or not, it's inevitable that healthcare is going to become a more important source of jobs over time. And that is happening around the world as well as in this country."
Demographic changesthe fact that elderly people are living longer, and that baby boomers are agingalso influence the demand for healthcare and for specific professional specialties. Already there are widespread shortages of people versed in geriatric care, from doctors and nurses to home-health aides. Still, the exact effect of the baby boomers on the healthcare industry is particularly debatable. Some analysts contend that the group will "age more healthily" than previous generations.
"Even if they do," cautions Ginsburg, "that doesn't necessarily mean they spend less or use less healthcare.... These healthy baby boomers aren't getting heart attacks in their 40s. But they might be taking new cholesterol-lowering drugs, getting their knees fixed, and using other services not available to generations before them. That might mean more is spent on healthcare." Offering another example, he points to a new type of job: "care coordinator"someone with nursing or other clinical credentials who oversees care for elderly patients with multiple medical problems. The job would likely be paid for by a health plan or a large provider organization.
A major factor that has curtailed interest by physicians in geriatric careand which clearly affects other healthcare professions and services now and in the futureis Medicare, the second-largest source of physician revenue. "Specialties in geriatrics [particularly for physicians] have not developed that well because in our current system, they are not paid very well," Ginsburg asserts. "It's economically pretty unattractive to invest in a specialty in which all of your patients are paid for by Medicare." As for current discussions over the future of Medicarepotential reforms and cutbacksGinsburg says only that "the degree to which private plans have a real cost advantage over the traditional program is very debatable."
The onset of managed care in the 1980s and 1990s brought aggressive price negotiations between insurers and hospitals and doctors; reimbursements were cut, and healthcare costs effectively contained. But those measures bottomed out by 1997, according to economist Shankar; since then healthcare costs have been rising again. "Today, however, with the maturation of Internet-based technology tools, managed care can offer far more customization and consumer control without adding administrative burden," Shankar says. "For this reason, I don't anticipate any dramatic pick-up in non-clinical positions in managed care at all. There will remain, however, accelerating demand for those familiar with the medical and information-technology worlds, as technological penetration in health care increases. Medical technicians and those able to manipulate information technology in a healthcare arena I think will be the real winners from this trend."
But Ginsburg sees a continued growth of "care-management activities," which could mean a mushrooming of nonclinical jobs, especially in fields related to health insurance. He suggests that there will probably be more employment in health plans, administrative positions, and related business jobs.
Managed care, Shankar believes, has also influenced the growing trend among seasoned doctors to leave clinical practice (or medicine altogether) for consulting, business opportunities in medicine, or concierge-style practices. ("Don't Fence Me In," a special report in the Harvard Medical Alumni Bulletin's spring 2003 issue, focused on physicians' views of the changing medical profession.) Physicians continue to voice dissatisfaction with working conditions and patient care because of HMO bureaucracy, escalating liability premiums, and a flattening of wages. In March, Ginsburg and colleague Marie C. Reed issued a data bulletin, "Behind the Times: Physician Income, 1995-1999," that identified an average five percent decline in physicians' real net income during the same time period in which most other professionals saw sharp salary hikes (see www.hschange.org/CONTENT/544/).
Interest in medical careers has also waned among the younger generation, Shankar says, citing a drop in medical-school applications during the last five or six years. For many years, conventional wisdom has pointed to a glut of doctors, but more recently, he says, some researchers have argued that the United States is headed for a physician shortage, at least in specialists. (Articles in the July-August 2003 issue of Health Affairs, The Policy Journal of the Health Sphere, at www.healthaffairs.org, examine the debate.) At this point, medical schools are still full, but more schools and slots will be needed to meet future demands, Shankar adds, noting that many rural areas still depend heavily on care from international graduate medical students (IMGs). Meanwhile, the future role of IMGs, who represent 24 percent of the physician workforce, is also an open question related to changing and tightening immigration policies.
The health of hospitalswhich is tied to Medicare, managed care, and other economic factorsalso influences healthcare jobs. "At this point, our information shows there is a shortage [for] literally every type of position in a hospital," says the AHA's Debra Stock. The financial roller-coaster ride experienced by many hospitalswhich find themselves inadequately compensated for labor and other costsmeans that "one-third of hospitals today are in the red, one-third are on the brink of going under financially, and one-third are doing OK," she says. Regulatory burdens weigh heavily. "One hour of care in the emergency room means one hour of paperwork. It's not a good way to keep people who went into the caring professions content." Nevertheless, Stock reports that hospitals around the country are coping with labor shortages by doing more to lure and retain long-term employees with better benefits, job flexibility, incentives for career advancement, and improved working conditions.
So is healthcare still a viable, stimulating profession with ample enough rewards? Yes, answers Spiro, in the Yale Guide's chapter, "Growing Old in Medicine." "Medicine [and healthcare] is still a wonderful career: Physicians have the chance to help people, to feel needed, and to enjoy the spiritual arrogance that comes from 'doing well by doing good.' That is a great feeling at the end of the day, and at the end of a life."
Nell Porter Brown is the assistant editor of this magazine.
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