Thursday, September 13, 2007

Service Jobs - Health Care

Health Care Services

We are looking for 92.8 million more service jobs. How about health care? For the sick or injured what could be more important than health care services? Employment in 2012 in the health care sector is 15.6 million divided among three sectors: ambulatory care, hospital care and nursing and residential care.

The federal government’s Standard Occupational Classifications define a group of 52 health care jobs called health care practitioners, who are mostly doctor, dentist, pharmacist, nurse, therapy and technology jobs. Health care practitioners actually deliver health care to patients and the jobs tend to have college and professional degree requirements. Few can be performed without a license. Combine all the health care practitioners and the total is 6.1 million jobs, which includes 539.9 thousand physicians and surgeons, 104.2 thousand dentists, 75.1 thousand pharmacists and 2.41 million registered nurses, the biggest occupation in health care.

There are 15 additional healthcare support occupations with 3.4 million jobs, all of them with aide, assistant or attendant in their job title. Nurse’s aides, orderlies and attendants are the second leading occupation in health care after registered nurses.

While a license is unusual for healthcare support jobs many of them have certificate or other formal training as eligibility requirements; usually these are vocational training or an AA degree rather than 4 year college degree training. Just like educational certification, health care degrees and certification programs provide a double employment benefit, keeping people out of the workforce and supporting employment at medical schools and college programs in allied health.

Licensed practitioners closely supervise nurse’s aides, orderlies and attendants or occupational therapist aide, physical therapist aide, pharmacy aide. Support jobs as health care aides free up time for licensed practitioners so their work tends to be filling forms, preparation and routine duties.

Health care practitioners and health care support occupations are two of what are really three segments of employment in health care. The third segment might be called administration and overhead. If we composed a one sentence summarization of health care jobs, here is how it would go: 6.1 million health care practitioners work to deliver health care with 3.4 million health care support staff along with 6.1 million other jobs as managers and non medical administrative staff.

If the American health care system had a similar history as public education it might not be as bloated with administration as it has come to be. With education people live somewhere and that somewhere is in a school district. Families with school age children send their children to the school in their district. The schools are publicly funded because they are vitally important to the social well-being. If we spend all that public money getting people educated it is not good for them to be ill and miss work, or die and not work at all, for lack of health care. Americans could have universal health care for all in districts like schools.

Instead America’s health care system is the evolution of political struggles beginning in the early part of the 20th century. By 1915 medical knowledge of antisepsis and anesthesia increased demand for health care enough to begin generating proposals for wide access to health care services. The American Medical Association was founded in 1847 so it was already well organized to oppose any plan that did not allow fee for service medicine. Even during the depression era when patients were unable to pay their bills, the AMA opposed government funded health care. They supported prepayment or private insurance plans like Blue Cross plans, but opposed proposals for health care coverage where the government would have a role.

Health care issues did not disappear with AMA opposition. The Truman administration supported a system of national health care with public funding and pushed hard for passage. The effort failed but political wrangling continued then as it continues today. In the arguments over government versus private insurance the Congress worked out various compromises that allowed a role for continued private insurance along with government funded health care programs. The political compromises in healthcare create bureaucratic employment: lots of it.

American health care has evolved into a decentralized public and private health care system with three large groups making transactions among themselves and with patients. On the medical side we have health care venders: hospitals, laboratories, clinics, HMO’s, PPO’s, independent practice offices, groups and associations. They do business among themselves and with the second major player in health care: private insurance companies. Federal, state and local government health care administrations round out the trio.

Universal coverage would consolidate administration and reduce the need for the multitude of separate bureaucracies. With universal health care it is easy to imagine standard forms and standard procedures. Since the health care industry supports 2.6 million jobs in Office and Administrative occupations, there are lots of jobs at stake. These include nearly 614,940 jobs as bill and account collectors, billing and posting clerks, file clerks and general office clerks involved with the billing shuffle. Bill processing needs computer support and there are about 98,660 jobs in computer work within the health care industry. Add over 764,030 jobs as secretaries, 415,380 jobs as receptionists and information clerks, and another 100,860 jobs in bookkeeping and accounting.

The Office and Administrative jobs and computer jobs just mentioned are all jobs within the health care industry, meaning ambulatory health care, hospitals, nursing and residential care. However, when bills and accounts are prepared for processing they have to be sent somewhere and to someone. Sending out is only half the transaction; someone else has to take them in; a someone who is part of another bureaucracy.
In a mixed public and private health care system lots of bills go to private insurance companies. There are 461,800 jobs in companies primarily engaged in underwriting health and medical insurance. For companies primarily underwriting health care insurance we have to figure most of those 461,800 jobs are health care administration since insurance companies do not deliver services to patients.

Claims adjusters are 10 to 12 percent of jobs in the health insurance industry and more than 10 percent are customer service representatives with some individual firms having over 20 percent of their staff in customer service. Customer service representatives within the health care industry total 89,700 jobs so we can see where billing troubles end up. There is more private sector health care administration because health care delivery continues to get more decentralized into independent practice associations, preferred provider organizations and HMO’s offering new forms of health care coverage. Some of these new groups are contracting their billing services to companies in the administrative support services industry.

Health care administration generates jobs in hundreds of decentralized state and federal offices administering Medicare, Medicaid, Social Security Disability, Workmen’s Compensation or the Veterans healthcare administration. When private health insurance expanded rapidly in the 1950’s the companies realized quickly that high risk individuals are unprofitable. Insurance companies do not want disabled, heart, diabetes, or arthritis patients so they tend to exclude them as having preexisting conditions. But private insurance will always leave out large numbers because many are too expensive to insure, or too poor to pay their premiums.

The unwanted groups have been big enough that political pressure brought a succession of unplanned and erratic compromises, which have at least one thing in common. They create separate programs with separate bureaucracies that create lots and lots of administrative jobs. In the public realm we have Medicaid, which is health care for the unwanted poor. Medicaid is a federal program with federal guidelines but it is administered through 50 state bureaucracies. The law includes authority for the states to customize their programs so Medicaid is different from one state to another.

Also in the public realm, we have health care for the unwanted retired and elderly, which is Medicare. Medicare is also a federal program, but it is administered state by state with separate administrative contractors processing claims. Medicare does not cover an entire bill so private insurance companies sell Medigap policies to millions so one hospital visit or one physicians service visit can generate two bills and brings action at two bureaucracies.

Difficulties with the Medicare billing system brought Congressional modification in the early 1980’s. Congress decided that medical venders should be responsible for filing Medicare claims rather than patients. At that time they instituted the Assignment billing system. Under this system if medical venders accept the Medicare payment amount, meaning accept assignment, they receive rapid payment directly from Medicare. If they wanted to charge more they would file the claim but request larger payment from their patient and the smaller Medicare amount would eventually go to the patient.

Using the new system required a delicate judgment by medical venders. Will the patient have the money and the willingness to pay? If the vender does not accept assignment and then cannot get full and timely payment from their patients, collection can take lots of staff time or bills may have to go to collection agencies. For anyone who has worked to decipher an Explanation of Medicare Benefits form it is easy to understand Medicare generated job creation in collection agencies.

Workmen’s compensation, which is really health care for people injured on the job, operates under federal guidelines through 50 state bureaucracies, but the states allow private companies to write the insurance so it supports jobs in private companies and independent insurance agencies. Military veterans have a separate health system, which supports another bureaucracy. Disability coverage supports additional bureaucracy since administration is through the social security administration and several specialty programs passed by Congress as well as private companies.

National health care should lead to standardization and efficiency. But we have to be careful about efficiency. Even though there is plenty of opportunity to be more efficient with health care, a modest 10 percent improvement in the health care office productivity would eliminate at least 260,000 office and administration support jobs. That is just the health care industry jobs; private sector insurance and government jobs would decline as well. Advocates of universal health care will need to consider how they will cope with these job losses.

Jobs requiring specialized professional degrees in medicine make up only 6.2 percent of health care employment. The total includes pharmacists, optometrists, dentists, orthodontists along with the physicians mentioned above. Another 3.1 percent need graduate degrees to be qualified to do some types of medical research, counseling, or physical therapy jobs. Jobs that use BA degree skills are more likely to be in health care management, finance or computing than delivering health care to patients, but these jobs have 7.8 percent of employment in health care.

Associates degree skills have more importance to health care than the BA degree with 20.9 percent of health care jobs that need AA degree skills. Partly that is due to nursing since AA degree candidates qualify to take state nursing exams even though many registered nurses complete BA and MA degrees. Registered nurses make up 14.6
percent of jobs in health care.

The associate’s degree in specialized health programs also assures entry level skills for 15 other health occupations as health technologists and technicians including diagnostic medical sonographers, radiological technicians and technologists, nuclear medicine technologists, medical records and health information technicians and others. Their numbers continue to rise.

If we total jobs that need college degree skills in professional, graduate, BA, and AA degree programs it comes to 38 percent of health care employment. Post secondary training leading to a certificate or similar non-degree award make up another 18 to 19 percent of jobs in health care. Programs last from a week or up to as much as a year or two. These additional jobs include licensed practical nurse, medical transcriptionist, orderlies, and nursing assistants. Remaining jobs need only walk on skills for a high school graduate of GED graduate.

With a 115.3 million jobs to divvy up health care employment gives us 15.6 million jobs and that is 11.7 percent of establishment employment. Health care industry employment has been growing at double the national rate since at least 1990, despite leaving millions without health care insurance. The high growth rate will help to employ some of the new entrants to the nation’s growing workforce, although it could help much more if health care coverage was available to all. Combine health care jobs with professional, scientific, technical services and education services and the total comes to 38.1 million service jobs. We have 77.2 million service jobs left to fill. Remember agriculture, mining and manufacturing jobs are in decline. We cannot expect to have more jobs in these industries. In the United States a job is a requirement and America needs to be meeting its requirements. We need service!


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