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Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.

Rural registered nurses (RNs) play an integral role in providing care for an underserved population with worse health outcomes than urban counterparts. However, little information is available on the profile of this workforce, which is necessary to understand the capacity of these nurses to provide quality and demanded care presently and in the future.We utilize data from the American Community Survey to provide a contemporary analysis on the supply of rural RNs in the United States.While the number of physicians serving rural populations has decreased in recent years, and rural nurse practitioners (NPs) remain in short supply, rural RNs have steadily grown in numbers at a rate comparable to urban RNs. Rural RNs are markedly less diverse than the populations they serve and only half of rural RNs had a bachelor's degree or higher compared to over 70% for urban RNs. In their supply, young rural nurses appear on pace with urban nurses to adequately replace older nurses and continue to grow the workforce, based on data through 2019.The rural RN workforce is projected to steadily grow amidst declining rural physicians and limited rural NPs. The burgeoning investments in the rural health workforce present opportunities to help diversify, increase educational access, and further rural readiness for rural RNs moving forward.

This cross-sectional study assesses a market basket price index to evaluate hospital outpatient department price levels and growth.

Concerns about physician shortages have led policy makers in the US public and private sectors to advocate for the greater use of nurse practitioners (NPs). We examined recent changes in demographi...

ImportanceA better understanding of the association between family structure and sex gaps in physician earnings and hours worked over the life cycle is needed to advance policies addressing persistent sex disparities.ObjectiveTo investigate differences in earnings and hours worked for male and female physicians at various ages and family status.Design, Setting, and ParticipantsThis retrospective, cross-sectional study used data on physicians aged 25 to 64 years responding to the American Community Survey between 2005 and 2019.ExposuresEarned income and work hours.Main Outcomes and MeasuresOutcomes included annual earned income, usual hours worked per week, and earnings per hour worked. Gaps in earnings and hours by sex were calculated by family status and physician age and, in some analyses, adjusted for demographic characteristics and year of survey. Data analyses were conducted between 2019 and 2022.ResultsThe sample included 95 435 physicians (35.8% female, 64.2% male, 19.8% Asian, 4.8% Black, 5.9% Hispanic, 67.3% White, and 2.2% other race or ethnicity) with a mean (SD) age of 44.4 (10.4) years. Relative to male physicians, female physicians were more likely to be single (18.8% vs 11.2%) and less likely to have children (53.3% vs 58.2%). Male-female earnings gaps grew with age and, when accumulated from age 25 to 64 years, were approximately $1.6 million for single physicians, $2.5 million for married physicians without children, and $3.1 million for physicians with children. Gaps in earnings per hour did not vary by family structure, with male physicians earning between 21.4% and 23.9% more per hour than female physicians. The male-female gap in hours worked was 0.6% for single physicians, 7.0% for married physicians without children, and 17.5% for physicians with children.Conclusions and RelevanceIn this cross-sectional study of US physicians, marriage and children were associated with a greater earnings penalty for female physicians, primarily due to fewer hours worked relative to men. Addressing the barriers that lead to women working fewer hours could contribute to a reduction in the male-female earnings gap while helping to expand the effective physician workforce.

Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.

Care management programs have become more widely adopted as health systems try to improve the coordination and integration of services across the continuum of care, especially for frail older adults. Several models of care suggest the inclusion of registered nurses (RNs) and social workers to assist in these activities. In a 2018 national survey of 410 clinicians in 363 primary care and geriatrics practices caring for frail older adults, we found that nearly 40 percent of practices had no social workers or RNs. However, when both types of providers did work in a practice, social workers were more likely than RNs to be reported to participate in social needs assessment and RNs more likely than social workers to participate in care coordination. Physicians' involvement in social needs assessment and care coordination declined significantly when social workers, RNs, or both were employed in the practice.

RESEARCH OBJECTIVE: To examine the type of services that are prone to “surprise billing” and the potential increased spending for patients and payers. STUDY DESIGN: Out‐of‐network billing occurs when patients receive services from providers that do not have a negotiated rate with the patient's insurer. While patients sometimes choose such providers knowingly (e.g., a preferred out‐of‐network mental health provider), out‐of‐network billing often occurs in scenarios outside of patients' control ‐ e.g., an out‐of‐network anesthesiologist participating in a surgery at an in‐network facility without patient knowledge ‐known as “surprise billing.” [Organization blinded] investigated “surprise billing” trends using the state's all‐payer claims database. POPULATION STUDIED: Patients insured by three large commercial payers in Massachusetts from 2015 to 2017 that had out‐of‐network indicators in their claims. These members represent over 15% of the state's commercially‐insured lives. PRINCIPAL FINDINGS: Among 657,140 commercially insured patients in 2017, we identified 68,342 distinct “surprise” claims, representing 30,332 Massachusetts residents (4.6%) during 44,689 healthcare encounters, in which patients most likely received care from out‐of‐network providers that they did not choose. Among these encounters, 10,590 (23.7%) were ambulance services, and 34,099 (76.3%) were professional services, primarily from ERAP providers (emergency, radiology, anesthesiology, or pathology). Among “surprise” professional services, 29.3% of encounters occurred within the emergency department (ED). Among the payers examined, 7.2 percent of ED visits in 2017 resulted in at least one “surprise” claim. The hospital outpatient department was the setting where most “surprise” professional encounters occurred, accounting for 82.6% of non‐ED out‐of‐network radiology claims, 71.2% of such pathology claims, and 65.5% of such anesthesiology claims. While claims data cannot substantiate whether a patient received a “balance bill” for any given encounter (when a patient is billed for the difference between the insurer's payment and the provider's charges on an out‐of‐network bill), we observed the potential for balance billing in more than 90% of “surprise” professional services claims. The average balance potentially billed to patients for these claims was $167 per claim but varied widely, ranging from $5 at the 5th percentile to $749 at the 95th percentile. Across a range of “surprise” procedures and ambulance services, average spending on out‐of‐network claims far exceeded average spending on in‐network claims. In addition, charges and payer‐paid amounts appeared to rise substantially over time. For example, for a moderate severity ED evaluation and monitoring (E&M) visit, the out‐of‐network charge grew 11% from $294 in 2015 to $325 in 2017. CONCLUSIONS: Out‐of‐network claims for ambulance and ERAP services continue to occur in the Massachusetts commercial market, potentially leading to higher premiums and burdening patients with unforeseen and large balance bills. IMPLICATIONS FOR POLICY OR PRACTICE: With recent federal and state legislative action to limit the practice of “surprise billing,” it is crucial to understand the practice's implications on payers, patients, and overall market functioning.

Four challenges face the nursing workforce of today and tomorrow: the aging of the baby boom generation, the shortage and uneven distribution of physicians, the accelerating rate of registered nurse retirements, and the uncertainty of health care reform. This article describes these major trends and examines their implications for nursing. The article also describes how nurses can meet these complex and interrelated challenges and continue to thrive in an ever-changing environment.

Growing Ranks of Advanced Practice Clinicians Nurse practitioners and physician assistants are providing an increasing share of health care services, and education programs have proliferated. These...

Implications of an Aging Rural Physician Workforce As fewer younger physicians enter rural practice in the United States, the rural physician workforce is graying and nearing retirement. The uneven...

In 2017, as part of a study to understand the evolving roles of nurses, physicians and social workers in leading and working in teams, our interprofessional team explored 22 sites of care for frail elderly adults in five US regions (Chicago IL, Denver CO, Tampa/Orlando FL, San Diego CA, New England).. The purpose of these site visits was to understand the current range of models of care for frail elders living in community, the roles of health professionals within those care models, and to inform national measure development. We selected regions based on elder population density, scope of NP practice, and screened over 100 sites to identify physician, nurse and social work led teams. We included general primary care, PACE, academic geriatrics, home based primary care, assisted living, FQCHC, palliative care, mobile health. We interviewed 108 key informants. We found considerable variation in staffing/elders within each site type.

Objectives The American Association of Colleges of Nursing recommends that nursing schools transition their advanced practice registered nurse (APRN) programs to doctor of nursing practice (DNP) programs by 2015. However, most schools have not yet made this full transition. The purpose of this study was to understand schools' decisions regarding the full transition to the DNP. Methods Key informant interviews and an online survey of nursing school deans and program directors were performed. Discussion The vast majority of schools value the DNP in preparing APRNs for the future of the health care system. However, other important factors influence many schools to fully transition or not to the postbaccalaureate DNP, including perceived student and employer demand, issues concerning accreditation and certification, and resource constraints. Conclusion Multiple pathways to becoming an APRN are likely to remain until various factors (e.g., student and employer demand, certification and accreditation issues, and resource constraints) yield a more favorable environment for a full transition to the DNP.

The Washington State legislature has recently considered several policy options to address a perceived shortage of primary care physicians in rural Washington. These policy options include opening the new Elson S. Floyd College of Medicine at Washington State University in 2017; increasing the number of primary care residency positions in the state; expanding educational loan-repayment incentives to encourage primary care physicians to practice in rural Washington; increasing Medicaid payment rates for primary care physicians in rural Washington; and encouraging the adoption of alternative models of primary care, such as medical homes and nurse-managed health centers, that reallocate work from physicians to nurse practitioners (NPs) and physician assistants (PAs). RAND Corporation researchers projected the effects that these and other policy options could have on the state's rural primary care workforce through 2025. They project a 7-percent decrease in the number of rural primary care physicians and a 5-percent decrease in the number of urban ones. None of the policy options modeled in this study, on its own, will offset this expected decrease by relying on physicians alone. However, combinations of these strategies or partial reallocation of rural primary care services to NPs and PAs via such new practice models as medical homes and nurse-managed health centers are plausible options for preserving the overall availability of primary care services in rural Washington through 2025.

Baby-boomer registered nurses (RNs), the largest segment of the RN workforce from 1981 to 2012, are now retiring. This would have led to nurse shortages but for the surprising embrace of the profession by millennials-who are entering the nurse workforce at nearly double the rate of the boomers. Still, the boomers' retirement will reduce growth in the size of the RN workforce to 1.3 percent per year for the period 2015-30.

The Patient Protection and Affordable Care Act (ACA) contains substantial new requirements aimed at increasing rates of health insurance coverage. Because many of these provisions impose additional costs on the states, officials need reliable estimates of the likely impact of the ACA in their state. To demonstrate the usefulness of modeling for state-level decisionmaking, RAND undertook a preliminary analysis of the impact of the ACA on five states—California, Connecticut, Illinois, Montana, and Texas—using the RAND COMPARE microsimulation model. For Connecticut, the model predicts that, in 2016 (the year that all of the provisions in the ACA related to coverage expansion will be fully implemented), the uninsured rate in Connecticut will fall to 5 percent; without the law, it would remain at 11 percent. The model projects that total state government spending on health care will be 10 percent lower for the combined 2011–2020 period than it would be without the ACA, mostly because of federal subsidies for residents who would have been covered by Connecticut's state-run health insurance program (State-Administered General Assistance).

The Center for Medicare and Medicaid Innovation within the Centers for MedicareMedicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Use of Sexual and Reproductive Health (SRH) services is projected to grow between 10 and 20 percent from 2006 to 2020. This growth is driven largely by changes in the racial/ethnic make-up of the population of women of reproductive age and an increase in the number of people with insurance coverage because of new health care legislation. Trends in supply and demand for SRH services, particularly for low-income individuals, suggest demand will outstrip supply in the next decade. Nurse Practitioners (NPs) with a women's health focus are key providers of SRH care in Title X-funded clinics, which deliver a significant proportion of U.S. family planning and SRH services to low-income populations. This article looks at why numbers of women's health NPs (WHNPs) have been declining, and are projected to continue to decline, despite significant growth in total numbers of NPs. Barriers to increasing the supply of NPs competent in SRH care-such as reduced funding for WHNP training, increased funding for primary care and geriatric NP training, and a shrinking proportion of WHNPs choosing to work in public health, clinics, and family planning-are identified. From the standpoint that the evolution of the health care delivery system may serve as an opportunity to optimize the delivery of SRH services in the United States, a comprehensive set of options spanning education, federal and state regulations, and emerging models of care delivery are explored to reverse this trend of too few WHNPs, particularly for servicing Title X facilities and their patients.

Social workers (SW) and community health workers (CHW) have emerged as key workforce personnel in efforts to care for elders in the U.S. However, little is known about the presence and roles of these professionals in outpatient practices. This paper presents findings from a nationally representative survey of geriatrics and primary care practices. Key findings include: reported challenges in meeting the social service needs of elders, underutilization of SW, and fuller utilization of social work competencies in practices in which both SW and CHW were present. These findings offer a unique perspective of SW on interprofessional teams and have implications for the future of the profession.

As the US population ages, primary care is expected to be the health care “home” for older adults, and several initiatives are aimed at helping to transform primary care practice to care for this population. Wide variation in staffing has been observed. Meyers et al proposed ideal models of primary care staffing for a general population and for a frail elderly population (2018). We developed the 2018 Survey of Primary Care and Geriatric Clinicians to measure optimal team configuration in clinical practices caring for older adults. A majority employed NPs, MDs and PAs, with [r = -.53] between % of clinician labor of NPs and physicians). High-NP practices are more likely located in states with full scope of practice, perform well for frail elders and are less expensive. Meyers' models, with fewer physicians, more SW and CHWs, more RNs, perform better for frail elders, and are less expensive.

Objective Policies that aim to steer patients from higher to lower cost providers of comparable quality have potential to impact health care cost growth – but their effectiveness depends, in part, on consumer perceptions of value and willingness to make tradeoffs. We sought to understand what was required to shift substantial numbers of consumers to higher-value care settings for several “shoppable” conditions. Methods A discrete choice experiment (DCE) was conducted to elicit patient preferences for hospital type. We used an Internet panel of 1005 Massachusetts residents to conduct this experiment in 2016. The DCE data were analyzed using alternative-specific conditional logit regression. Results Consumers reported large influences of out of pocket costs, physician referrals and quality ratings on their choice of hospital. For example, up to a third of consumers would shift from Academic Medical Centers to community hospitals if the latter had higher quality ratings, lower copays or a physician referral. Choice of site for maternity care was most influenced by physician referral; cancer treatment and orthopedic procedures by quality ratings; and MRI by cost, suggesting that patients prioritize quality over cost as perceived risk increases. Conclusions and implications Our findings provide guidance for identifying promising policy levers that most influence consumer choice of provider. However, the extent to which potential levers can influence choice is likely to be dependent upon the kind of care being sought.

Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. We analyzed the impact of two emerging models of care--the patient-centered medical home and the nurse-managed health center--both of which use a provider mix that is richer in nurse practitioners and physician assistants than today's predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management.

Foreign-educated and foreign-born health workers constitute a sizable and important portion of the US health care workforce. We review the distribution of these workers and their countries of origin, and we summarize the literature concerning their contributions to US health care. We also report on these workers' experiences in the United States and the impact their migration has on their home countries. Finally, we present policy strategies to increase the benefits of health care worker migration to the United States while mitigating its negative effects on the workers' home countries. These strategies include attracting more people with legal permanent residency status into the health workforce, reimbursing home countries for the cost of educating health workers who subsequently migrate to the United States, improving policies to facilitate the entry of direct care workers into the country, advancing efforts to promote and monitor ethical migration and recruitment practices, and encouraging the implementation of programs by US employers to improve the experience of immigrating health workers.

Microsimulation modeling is one tool in the arsenal available to policy makers for understanding the effects of potential policy changes. Such models have been used for decades in a variety of contexts, such as understanding the effects of tax rate changes (e.g., the TAXSIM model) and income support programs (e.g., the TRIM2 model). A distinguishing feature of microsimulation models is that the objects of the simulation are individual units—as opposed to aggregations of units—and their advantages include that they allow for examination of distributional effects of a policy change or other exogenous event and for understanding the effects of multiple, interacting policy changes (Chollet 1990; Giannarelli 1992; Mitton 2000). Recent years have witnessed the development and increased use of a number of microsimulation models designed to understand the effect of health care reform efforts, including the RAND COMPARE (Comprehensive Assessment of Reform Efforts) model, CBO's Health Insurance Simulation Model (HISim), and the Urban Institute's Health Insurance Reform Simulation Model (HIRSM), among others. These modeling efforts have largely been focused on understanding consumer demand for health insurance coverage and health care under a range of policy scenarios, along with the associated costs of policies in terms of government and societal spending. But simulation modeling efforts aimed at understanding the supply-side effects of health policies have been few and ad hoc—despite the fact that the Patient Protection and Affordable Care Act (ACA) includes a wide range of supply-oriented policy changes, and supply-side effects of major health reforms have the potential to dwarf demand-side effects under some circumstances (Stewart and Enterline 1961; Enterline, McDonald, and McDonald 1973; Finkelstein 2007). One factor underlying the relative paucity of supply side models is a lack of good data. As Citro (1991)emphasize: Good data are a critical ingredient for models and other analysis tools to produce good estimates. Data that are of poor quality, scope and relevance will increase the uncertainty and decrease the validity of model outputs. Poor data also make it harder for models to respond to changing policy analysis needs in a timely and cost-effective manner. Chollet (1990) notes further that: Much of the effort involved in building and maintaining microsimulation models relates to enhancing and imputing the input data necessary to support even relatively simple analysis. There are many supply-side entities in health care that may be useful to analyze in the context of a microsimulation model—including insurance companies, health plans, hospitals, urgent care centers, retail clinics, community health centers, physicians, nurse practitioners, psychologists, social workers, and others— to gauge the potential effects of the ACA. In this article, we focus for tractability on one key such entity in the health care market: physicians. The adequacy of the current supply of physicians to accommodate what is expected to be an increase in the number of insured individuals of nearly 30 million after full ACA implementation (Eibner and Price 2012) has been of particular concern (AcademyHealth 2012). We provide a framework for understanding the types of data required for supply-side microsimulation modeling, identify key data sources available to fulfill these needs in the context of a physician model, and assess and compare the strengths and limitations of data from various sources.

There has been concern that greater use of nurse practitioners (NP) and physician assistants (PA) in face-to-face primary care may increase utilization and spending.To evaluate a natural experiment within Kaiser Permanente in Georgia in the use of NP/PA in primary care.From 2006 through early 2008 (the preperiod), each NP or PA was paired with a physician to manage a patient panel. In early 2008, NPs and PAs were removed from all face-to-face primary care. Using the 2006-2010 data, we applied a difference-in-differences analytic approach at the clinic level due to patient triage between a NP/PA and a physician. Clinics were classified into 3 different groups based on the percentage of visits by NP/PA during the preperiod: high (over 20% in-person primary care visits attended by NP/PAs), medium (5%-20%), and low (5%) NP/PA model clinics.Referrals to specialist physicians; emergency department visits and inpatient admissions; and advanced diagnostic imaging services.Compared with the low NP/PA model, the high NP/PA model and the medium NP/PA model were associated with 4.9% and 5.1% fewer specialist referrals, respectively (P0.05 for both estimates); the high NP/PA model and the medium NP/PA model also showed fewer hospitalizations and emergency department visits and fewer advanced diagnostic imaging services, but none of these was statistically significant.We find no evidence to support concerns that under a physician's supervision, NPs and PAs increase utilization and spending.

Since the 1970s, a number of initiatives have attempted to increase the proportion of nursing graduates with a baccalaureate degree, but with little national effect. Now market forces, health reforms, and an Institute of Medicine report (2011) have combined to transform the educational composition of the nursing workforce. Today, there are considerably more graduates of baccalaureate nursing programs than associate degree programs. The educational transformation of the nursing workforce is not limited to baccalaureate education but includes the rapidly increasing numbers of registered nurses who have earned graduate degrees. These changes in nursing education are increasing the readiness of nursing professionals to capitalize on new opportunities, overcome challenges, and take on new roles and responsibilities as the nation's health care delivery and payments systems evolve in coming years.

Objective To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Data Sources State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals. Study Design Retrospective study using cross-sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures. Data Collection/Extraction Methods Hospital-level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada. Principal Findings Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross-sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross-sectional models and none in longitudinal models. Conclusions After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.

The nurse practitioner (NP) workforce has been a focus of considerable policy interest recently, particularly as the Patient Protection and Affordable Care Act may place additional demands on the healthcare professional workforce. The NP workforce has been growing rapidly in recent years, but fluctuation in enrollments in the past decades has resulted in a wide range of forecasts.To forecast the future NP workforce using a novel method that has been applied to the registered nurse and physician workforces and is robust to fluctuating enrollment trends.An age-cohort regression-based model was applied to the current and historical workforce, which was then forecasted to future years assuming stable age effects and a continuation of recent cohort trends.A total of 6798 NPs who were identified as having completed NP training in the National Sample Survey of Registered Nurses between 1992 and 2008.The future workforce is projected to grow to 244,000 in 2025, an increase of 94% from 128,000 in 2008. If NPs are defined more restrictively as those who self-identify their position title as "NP," supply is projected to grow from 86,000 to 198,000 (130%) over this period.The large projected increase in NP supply is higher and more grounded than other forecasts and has several implications: NPs will likely fulfill a substantial amount of future demand for care. Furthermore, as the ratio of NPs to Nurse Practitioners to physicians will surely grow, there could be implications for quality of care and for the configuration of future care delivery systems.

Although a median-income US family of four with employer-based health insurance saw its gross annual income increase from $76,000 in 1999 to $99,000 in 2009 (in current dollars), this gain was largely offset by increased spending to pay for health care. Monthly spending increases occurred in the family's health insurance premiums (from $490 to $1,115), out-of-pocket health spending (from $135 to $235), and taxes devoted to health care (from $345 to $440). After accounting for price increases in other goods and services, the family had $95 more in monthly income to devote to nonhealth spending in 2009 than in 1999. By contrast, had the rate of health care cost growth not exceeded general inflation, the family would have had $545 more per month instead of $95-a difference of nearly $5,400 per year. Even the $95 gain was artificial, because tax collections in 2009 were insufficient to cover actual increases in federal health spending. As a result, we argue, the burdens imposed on all payers by steadily rising health care spending can no longer be ignored.

Key Points Question Is the growth of accountable care organizations associated with changes in physician work hours, probability of being self-employed, and probability of working in a hospital? Findings In this cross-sectional study including 49 582 physicians, a 10–percentage point increase in accountable care organization enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 work hours per week among male physicians. In addition, the 10–percentage point increase was associated with a decrease of 2% in the probability of all physicians being self-employed. Meaning These results suggest that accountable care organizations may affect physician employment patterns., Importance The share of the population covered by accountable care organizations (ACOs) is growing, but the association between this increase and physician employment is unknown. Objective To investigate the association between the growth of ACOs and changes in physician work hours, probability of being self-employed, and probability of working in a hospital. Design, Setting, and Participants A fixed-effects design was used in this cross-sectional study to compare changes in physician employment in hospital referral regions with high vs low ACO growth. A nationally representative 1% sample of all working US physicians obtained annually from 2011 through 2015 from the American Community Survey (N = 49 582) was included. Data analysis was conducted from March 28, 2017, to April 10, 2018. Main Outcomes and Measures Physician hours worked per week, probability of being self-employed, and probability of working in a hospital. Results Of the 49 582 physicians included in the study, 63.5% were men; the mean (SD) age of sampled physicians was 46.01 (11.59) years. In 2011, sampled physicians worked a mean (SD) of 52.2 (16.1) hours per week, 24.43% were self-employed, and 42.03% worked in a hospital. A 10–percentage point increase in ACO enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 (95% CI, −1.52 to −0.13; P = .02) work hours in men and a decrease of 2% (95% CI, −3.8% to −0.1%; P = .04) in the probability of all physicians being self-employed. The association with self-employment was strongest (−5.0%; 95% CI, −8.7% to −1.4%; P = .006) in physicians aged 50 to 69 years, who were also more likely (4.0%; 95% CI, 1.0% to 6.9%; P = .009) to work in a hospital. Conclusions and Relevance The growth of ACOs within hospital referral regions appears to be associated with a reduction in hours of work and self-employment among physicians. These results suggest that ACOs may affect physician employment patterns., This cross-sectional study evaluates the association between the expansion of accountable care organizations throughout the United States and changes in physician work hours, self-employment, and employment in hospitals.

Registered nurse (RN) employment has increased during the current recession, and we may soon see an end to the decade-long nurse shortage. This would give hospitals welcome relief and an opportunity to strengthen the nurse workforce by addressing issues associated with an increasingly older and foreign-born workforce. The recent increase in employment is also improving projections of the future supply of RNs, yet large shortages are still expected in the next decade. Until nursing education capacity is increased, future imbalances in the nurse labor market will be unavoidable.

Although the number of people entering nursing in their early to mid-twenties remains at its lowest point in forty years, large numbers of people are entering the profession in their late twenties and early thirties. And although it remains unclear why people are becoming nurses later, there is evidence that nursing is attracting interest from different segments of the potential workforce than it was in the 1970s and 1980s. We analyze these trends using data through 2005 and a revised forecast model that still predicts a nurse shortage by 2020, but a smaller one than previously forecast.

Providing regional projections of the RN workforce will allow underlying differences in the age structure of the RN workforce to become more visible. By providing regional-level projections, it will also be possible to identify those regions whose RN workforce is expected to grow at a slower rate relative to other regions. States in the South and Midwest have a greater supply of younger-aged RNs available to replace fewer numbers of older-age RNs compared to other regions. In contrast, the Northeast and West have fewer younger RNs currently in their workforce yet a relatively larger number of older age RNs to replace. These differences in age structure may be partly due to differences in nursing school enrollment and expansion in nursing education capacity across regions. This information can help guide national and state health workforce planners, employers, educators, and others in developing policies and initiatives that may impact nursing supply in their states.

Importance After forecasts made more than a decade ago suggested dire nursing shortages, enrollment in nursing schools doubled. The implications of this unprecedented change for the nursing workforce have not yet been fully explored. Objective To forecast the size and age distribution of the nursing workforce to the year 2030 and to compare to demand recently projected by the Health Resources and Services Agency. Design A retrospective cohort analysis of employment trends by birth year and age were used to project age and employment of registered nurses (RNs) through 2030. Setting Data on employed RNs from the United States Bureau of the Census Current Population Survey (1979-2000, N=72,222) and American Community Survey (2001-2013, N=342,712). Participants RNs between the ages of 23 and 69 years. Main outcome measure Annual full-time equivalent (FTE) employment of RNs in total and by single year of age. Results Annual retirements from the nursing workforce will accelerate from 20,000 a decade ago to near 80,000 in the next decade as baby boomer RNs continue to age. We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce. Overall, we project that the registered nursing workforce will increase from roughly 2.7 million FTE RNs in 2013 to 3.3 million in 2030. We also find that the workforce will reach its peak average age in 2015 at 44.4. This increase in workforce size, which was not expected in forecasts made a decade ago, is contingent on new entry into nursing continuing at its current rate. Even then, supply would still fall short of demand as recently projected by the Health Resources and Services Agency in the year 2025 by 128,000 RNs (4%). Conclusions The unexpected surge of entry of new RNs into the workforce will lead to continued net growth of the nursing workforce, both in absolute FTE and FTE per capita. While this growth may not be sufficient to meet demand, such projections are uncertain in the face of a rapidly evolving health care delivery system.

Growth in the number of RN graduates from 2002-2012 has been dramatic and broad based, occurring between both associate and baccalaureate programs, and has included people from all racial and eth- nic backgrounds. This growth has occurred in all types of public, private not-for- profit, and proprietary institu- tions. The growth of RNs with gradu- ate degrees has also increased, particularly since 2004. Given the rapid production of nursing graduates, leaders in academic nursing education are urged to focus on the quality of nursing graduates, take steps to assure that graduates are well prepared for growth in nonhospital settings, ensure graduates are aware of the many challenges they will confront, and are well prepared to seize opportunities that will unfold during an era of health reform.

Roughly 40% of the nearly 3 million registered nurses (RNs) in the United States have an associate's degree (ADN) as their highest level of nursing education. Yet even before the recent Institute of Medicine report on The Future of Nursing, employers of RNs have increasingly preferred baccalaureate-prepared RNs (BSNs), at least anecdotally. Data from the American Community Survey (2003-2013) were analyzed with respect to employment setting, earnings, and employment outcomes of ADN and BSN-prepared RNs. The data reveal a divergence in employment setting: the percentage of ADN-prepared RNs employed in hospitals dropped from 65% to 60% while the percentage of BSN-prepared RNs employed in hospitals grew from 67% to 72% over this period. Many ADNs who would have otherwise been employed in hospitals seem to have shifted to long-term care settings.

The importance of registered nurses is expected to increase under health care reform. Thanks to a surge in RN graduates, predicted workforce shortages have not materialized. But some uncertainties still threaten the sufficiency of the workforce in the future.

Wage increases, relatively high national unemployment, and widespread private-sector initiatives aimed at increasing the number of people who become nurses has resulted in a second straig...

Hospital employment of registered nurses (RNs) increased dramatically during the recession, making it seem as if the decade-long national shortage of RNs had ended. But RN employment is countercyclical, and the bubble is likely to burst during the next several years.

Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care.To assess the effect of nurse staffing on quality of care and inpatient care costs.Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011.Hospital discharges from California, Nevada, and Maryland (n=18,474,860).A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics.Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs.The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

It may be time for the Veterans Health Administration to transition out of the health care delivery business, instead supporting utilization of private-sector health care by subsidizing coverage for enrolled veterans and coordinating care for its service population.

The size of the registered nurse (RN) workforce has surpassed forecasts from a decade ago, growing to 2.7 million in 2012 instead of peaking at 2.2 million. Much of the difference is the result of a surge in new nursing graduates. However, the size of the RN workforce is particularly sensitive to changes in retirement age, given the large number of baby-boomer RNs now in the workforce. We found that in the period 1969-90, for a given number of RNs working at age fifty, 47 percent were still working at age sixty-two and 9 percent were working at age sixty-nine. In contrast, in the period 1991-2012 the proportions were 74 percent at age sixty-two and 24 percent at age sixty-nine. This trend, which largely predates the recent recession, extended nursing careers by 2.5 years after age fifty and increased the 2012 RN workforce by 136,000 people. Because many RNs tend to shift out of hospital settings as they age, employers seeking RNs for nonhospital roles may welcome (and seek to capitalize on) the growing numbers of experienced RNs potentially able to fill these positions.

Registered nurses (RNs) comprise the largest segment of the healthcare workforce, numbering more than 2.5 million in the US in 2010. The nursing workforce faces institutional rigidities – more so than with physicians but less so than with aides or medical assistants – and are thus not only somewhat responsive to typical market forces of supply and demand but also prone to temporary shortages. As most RNs are female and often part of two-income households, their labor supply decisions are particularly affected by childbearing decisions and the state of the economy. A growing segment of the workforce is advanced practice RNs, who have obtained additional education and perform work that overlaps substantially with physicians.

Purpose: To assess the extent to which the number of minority RNs has grown during the past 20 years, and to identify and compare key trends in personal and professional characteristics among minority groups and between minority and majority populations of RNs. Nursing education programs, employers, philanthropic organizations, and governments have expended considerable effort and resources to increase the number of minorities in nursing. Design: Longitudinal analysis of trends in the number, education, employment, and earnings of minority RNs from 1977 to 1997. Methods: Descriptive analysis of data from the U.S. National Sample Surveys of the Population of Registered Nurses, 1977-1996; and data from the U.S. Bureau of the Census Current Population Survey (CPS) Outgoing Rotation Croup Annual Merged Files, 1977-1997. Findings: In the past 20 years, the number of minority RNs has grown from 87,386 (or 6.3% of the total supply of RNs) in 1977 to 246,364 RNs (9.7%) in 1996. The number of Black (nonHispanic), Asian Pacific/Islanders, and American Indian/Alaskan Native nurses nearly tripled in this period while the number of Hispanics doubled. Although these rates of growth are impressive, the percentage of minorities in nursing lags considerably behind the percentage (18.3%) who are teachers, and the percentage (28.2%) in the U.S. population. Conclusions: Studies are needed to determine the barriers that exist in nursing education programs, health care organizations, and society in general that deter minorities from a nursing career. Without this understanding, efforts to design and implement ideas to attract, educate, and retain minorities in nursing education and later in the workplace are hampered.