Cecil G. Sheps Center for Health Services Research,
The University of North Carolina at Chapel Hill

April 2018
Data and Workforce Policy: The Indispensable Role of States

States are responsible for most of the policy direction for the health care workforce. They license health professions and regulate the types of services they can provide. The state also invests significant public money in training the future workforce. Having data to support the many decisions state legislatures, agencies and institutions ask is essential to effectively and equitably meet the health care needs of North Carolina's citizens.
The Program on Health Workforce Research and Policy at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina plays an important role in gathering, analyzing and disseminating workforce data needed to inform state policy. Examples highlighted in this newsletter show how our data are being used to evaluate whether the State of North Carolina should develop a new School of Health Sciences at UNC Pembroke and new programs to train physician assistants and doctors of chiropractic medicine at Winston Salem State University. The newsletter also highlights work underway to help legislators more effectively evaluate scope of practice debates and understand the oral health and psychologist workforces.   
Health Workforce Analysis for Education Program Planning

Developing a School of Health Sciences and Health Care at the University of North Carolina at Pembroke (UNC-P)

The 2017 State Appropriations Act directed the Board of Governors (BOG) of the University of North Carolina (UNC) to study the feasibility of establishing a School of Health Sciences and Health Care at the University of North Carolina at Pembroke (UNC-P). The Program on Health Workforce Research and Policy conducted a study that examined the pros and cons of five potential health programs: nurse practitioner studies, occupational therapy, optometry, nutrition and dietetics, and physician assistant studies. The analysis also identified how training in healthcare management, health informatics, and public health/population health education could be woven through the curriculum of all health programs and provided as separate degrees, or delivered in certificate programs. The report noted that new health sciences programs at UNC-P could help improve the supply of health professionals in the region, increase the racial and ethnic diversity of the health workforce, and provide access to well-paying health care jobs.

In the News
The Potential for a Physician Assistant Program at Winston-Salem State University
The same appropriations act mandated that the UNC Board of Governors (BOG) also study the feasibility of establishing a physician assistant (PA) program at Winston-Salem State University (WSSU). The UNC System asked the Program on Health Workforce Research and Policy to conduct a study of PA supply and demand in North Carolina and assess the feasibility of a new program at WSSU. The case for a new PA program at WSSU is unclear. On one hand, the demand for PAs is strong and the demand for students is such that, despite the growth in seats at training programs, the number of applicants per seat has grown. At the same time, PA programs have expanded rapidly in the state and in the country over the past six years. A key challenge facing a new PA program is the lack of available preceptors in the state to train learners. A PA program at WSSU, a historically Black university, could potentially increase the diversity of the PA workforce in North Carolina if graduates remain in-state. However, it is unclear whether PA students would reflect the diversity of the rest of WSSU's student body. Currently, only two PA programs in the state are located at public universities with in-state tuition.

The Potential for a School of Chiropractic Medicine at Winston-Salem State University

Similarly, the appropriations act mandated the UNC BOG to study the feasibility of establishing a school of chiropractic medicine at WSSU. The report noted that it is difficult to determine whether NC has a surplus or a shortage of chiropractors because most of the health conditions they treat can also be treated by other clinicians, including physicians, physical therapists, massage therapists, or alternative medicine providers. While some interviewees suggested that demand might increase if patients seek natural pain remedies due to greater awareness of the opioid epidemic, data that support this claim are not available. National data indicate that the patients who seek chiropractic care tend to have higher incomes and are more likely to be white. Few chiropractors in NC identify as underrepresented minorities and it is unclear whether locating a school at a historically Black university would increase awareness of the profession among students from underrepresented backgrounds. All 17 chiropractic schools in the U.S. are located at private institutions. A prior attempt to start a chiropractic school at a public university, Florida State, failed in 2005 due to political controversy.

In the News
The Psychologist Workforce in North Carolina: Expanding Access for Patients in Rural Areas

The Program on Mental Health and Substance Abuse Services and Systems and our workforce research program teamed up to examine trends in the North Carolina psychologist workforce. The analysis was conducted at the request of the UNC General Administration and was aimed at identifying the factors influencing whether clinical psychologists to practice in rural areas. The findings helped provide a context for evaluating the need to expand clinical psychology doctoral programs in the state. Results will be published in an upcoming article by Domino et al in the Journal of Rural Health: Are Psychologists an Answer to Rural Mental Health Workforce Shortages?: Exploring Opportunities and Constraints. (in press)
In March 2018, the UNC Board of Governors granted approval to Appalachian State University to develop a new Doctor of Psychology (Psy.D.) program , with a primary goal of training students in clinical psychology to serve rural populations. The new program plans to admit students beginning in the fall of 2019.

Using Data to Evaluate the Need for New Educational Programs

For additional examples of analyses to support decision-making, outcomes of those decisions, and fiscal implications, see our
2017 policy brief . 
Updated Data on North Carolina's Dentist Workforce
Julie Spero, Director of the NC Health Professions Data System, presented newly updated data on NC's oral health workforce to various stakeholder groups across the state. Recent findings include:
  • There were 5,112 actively licensed dentists practicing in NC in 2017.
  • Between 2013 and 2017, North Carolina's ranking moved from 44th to 37th nationally for  dentist-to-population ratio, from 4.8 to 5.1 dentists per 10,000 population (the national average in 2017 was 6.1 dentists per 10,000 population).
  • However, 72% of the growth in dentists (397 of 551) between 2013 and 2017 occurred in just 5 counties: Buncombe, Mecklenburg, Orange, Pitt, and Wake. All five counties, which were already well-supplied, saw an increase in dentists relative to population.
  • Access to dental care is broader than the supply of dentists. Dental care is prohibitively expensive for many who need it.
Helping Legislators Understand Scope of Practice

Scope of practice (SOP) issues are emerging with increased frequency due to concerns about workforce shortages, rising health care costs and access to care issues. When debated at the North Carolina General Assembly, proposals to change SOP involve a range of stakeholders with strong positions that are often focused on professional self-interests, not those of patients.
On April 9, Erin Fraher led a group of legislators engaged with the   North Carolina Institute of Medicine Legislative Fellows Program in an exploration of scope of practice issues in North Carolina. The group voiced their appreciation at gaining a deeper understanding of SOP issues facing the state and tools they could use to more effectively evaluate scope of practice issues in the future.
NC Health Professions Data System Used as a Model in Other States
Arizona cites NC HPDS in report to legislature
Many states lack basic data and information about the health workforce that would inform policymakers and other stakeholders on questions about health professional supply, demand, and demographic, education and practice characteristics, as well as questions pertaining to training, recruitment, retention and financing. Since 2003, and in collaboration with the Health Workforce Technical Assistance Center since 2013, the North Carolina Health Professions Data System has been a resource to states interested in developing state-level health workforce data systems.

In 2017, Arizona appointed an Ad Hoc Committee on Health Care Workforce to make recommendations on developing, financing and overseeing the collection of data on health care workers. Their final report included expertise from NC's HPDS, as well as resources from the Health Workforce Technical Assistance Center . The Committee's recommendations resulted in HB 2197 , which passed the House 60-0 in February and is currently under review by the Senate.
In case you missed it
Our February 2018 newsletter, which focused on evaluating the workforce outcomes of North Carolina medical education programs, is available here .
Recent presentations
Fraher E, Spero J, Galloway E, Gaul K, Kandrack R. The Sheps Center Program on Health Workforce Research and Policy: Providing evidence to support health workforce policy in North Carolina . MAHEC Academic Steering Leadership Group, UNC Health Sciences at MAHEC. Asheville, NC. March 13, 2018.
Fraher E, Spero J, Ricketts T, Galloway E, Gaul K. Challenges and Opportunities Facing the North Carolina Health Workforce . Health Deans Meeting, UNC System. Chapel Hill, NC. March 2, 2018.

In the news
Erin Fraher and Mark Holmes were quoted in a North Carolina Health News article by Rose Hoban about rural health, physician supply and GME outcomes in the state.
Our work on measuring the outcomes of medical and graduate medical education programs in North Carolina has been featured by the John Locke Foundation in their blog, The Locker Room:
Upcoming seminar 
Health Workforce Seminar Series , with support from Carolina Seminars , brings together a diverse group of academic scholars, students, practicing health professionals, and policy experts from around the country to discuss health workforce policy and planning. Previous speakers have included state and Federal legislators, national researchers, international health workforce planners, AHECs, educators and health professionals. Topics have included behavioral health, interprofessional education and practice, new and emerging models of care, using data to inform policy, the VA Healthcare System and health professions education.
The next seminar is scheduled from 11:00-12:30 pm on April 26th at the Sheps Center. Jane Weintraub, DDS, MPH, Alumni Distinguished Professor, UNC School of Dentistry will present on "Integrating Primary Care and Oral Health."

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