This article is the third in a series on COVID-19 and the District’s health care workforce which will discuss the ecosystem of care providers relevant to COVID-19 and primary care outcomes, evaluate patients’ access to clinicians, and measure health care capacity. Read the other articles in the series:
Read the other articles in the series:
Since March 2020, over 33 million people have contracted COVID-19 in the United States.[1] Compared to the national average and many other large metropolitan areas, D.C. fared relatively well, with a case rate of 6,996 per 100,000 people, compared to the national average of 10,140 per 100,000 people.[2],[3] While many elements contributed to D.C. ‘s relatively low case rate during COVID, one factor is the existing health infrastructure, including the quantity of healthcare workers.
In previous articles in this series, we have focused specifically on health care workforce and health care demand within the District of Columbia. However, modest distances are frequently traveled by individuals seeking health care. Additionally, health care providers are relatively mobile in terms of employment and may relocate to a different city while staying within the broader region (e.g., in order to retain within-state licensure). Therefore, this article focuses on the ecosystem of health care providers in the metropolitan statistical area (MSA) in addition to looking within city boundaries (see the previous piece in this series on the number of healthcare workers within D.C.), and compares the size and composition of the D.C. region’s health care workforce to areas with similar demographics.
The District’s health care workforce has high numbers of clinicians, as there are seven private hospitals in D.C., as well as a Veterans Affairs hospital, children’s hospital, and six specialty hospitals, in addition to more than 50 primary care facilities and urgent care facilities. D.C. also has three medical schools, as well as many other universities offering programs to become nurses, physician assistants, medical assistants, and respiratory therapists. The D.C. clinical environment offers ample opportunity to recent graduates in the healthcare field and also attracts health care workers from other areas because of its density, the quality of healthcare facilities, and competitive salaries. For instance, the average annual nursing salary with a bachelor’s degree in D.C. is almost $94k, compared to the national average of $79k.[4]
Due to the relative ease of travel and providers’ ability to move between areas in the metro region, focusing on the District alone will conceal whether people in the metropolitan area have adequate access to health care. In contrast to the District’s high concentration of medical schools and facilities, and population of approximately 700,000 people, the Washington, D.C. metropolitan statistical area (alternatively the “Washington MSA”) has a population of 6.3 million people and sprawls from Spotsylvania, VA in the southwest to Calvert and Prince George’s counties in the east, and Frederick, MD in the north. Given that providers can move around the region and that people often travel for medical care, we wondered: How does the Washington D.C. metropolitan area’s healthcare capacity compare to other similar jurisdictions within the United States?
To see how the D.C. area compares to other MSAs, we chose the following six jurisdictions, which, like the Washington MSA, have medical schools and other health care teaching institutions producing a pipeline of health care clinicians (HCCs), are racially and ethnically diverse, and are hubs for travel and business:
- Atlanta MSA (areas in and surrounding Atlanta, Sandy Springs, and Roswell, GA)
- Baltimore MSA (areas in and surrounding Baltimore, Columbia, and Towson, MD)
- Dallas MSA (areas in and surrounding Dallas, Fort Worth, and Arlington, TX)
- New York MSA (areas in and surrounding New York, NY, Newark, NJ, Jersey City, NJ NY-NJ-PA):
- Philadelphia MSA (areas in and surrounding Philadelphia, Camden, and Wilmington, PA-NJ-DE-MD)
- San Francisco MSA (areas in and surrounding San Francisco, Oakland, and Hayward, CA)
How does the Washington MSA compare to other jurisdictions?
Within the Washington MSA, registered nurses (682 per 100,000 people) far outnumber all other types of healthcare providers. Home health aides (561 per 100,000 people) make up the second largest share of the workforce, while doctors (254 per 100,000 people) are the third most abundant HCC group. The allied health workforce includes medical assistants and home health aides, the latter of whom have provided in-home care during the pandemic even at great personal risk.[5] Physician assistants, respiratory therapists, and occupational therapists have also been vital front-line workers during the pandemic, although there are fewer per capita than other clinicians.
While the Washington MSA has the second-highest rate of physicians and surgeons among the comparative cohort—trailing just New York—it trails the bulk of the cohort for its supply of other HCCs. For all other providers besides respiratory and occupational therapists, the Washington MSA is sixth among the seven-member cohort. Its population-adjusted count of respiratory therapists (20 per 100,000 population) is just more than half that of the cohort-wide average (37 per 100,000 population). Accordingly, the Washington MSA trails the cohort-wide average for every HCC type besides physicians and surgeons.
What part does each specialty play in the health care ecosystem and COVID response?
Physicians and surgeons
During the COVID-19 pandemic, physicians and surgeons handled a variety of interventions ranging from intensive care unit (ICU) ventilation treatment and blood filtration on the invasive end, to more straightforward practices such as the administration of antiviral drugs. Importantly, they also make critical decisions about which treatments to administer, and especially during the early days of the pandemic, were making decisions about elective surgeries and other procedures.
With a physician workforce of 254 per 100,000 population, the Washington MSA is near the top of its comparative cohort but falls far short of leaders such as Massachusetts, which has the highest per capita physician supply of any state (449.5 per 100,000 population). The Washington region’s physician supply is similar to, but less than, the nationwide average in 2018 (277.8 active physicians per 100,000 population).[6]
On a global scale, according to a 2018 Kaiser Family Foundation survey of physicians per-capita worldwide, the U.S. physician density, and the similar Washington MSA physician density, fall short of those of peer countries, such as Austria (520 per 100,000 population), Switzerland (430 per 100,000 population), and France (320 per 100,000 population).[7]
Physician assistants (PAs)
As the U.S. scrambled to mount a workforce response to the COVID-19 pandemic, several jurisdictions relaxed or removed supervision requirements and made it easier for physician assistants (PAs) to cross state borders, which in some cases meant going from more-restrictive to less-restrictive environments.[8] The Washington region’s relatively strong per-capita count of physicians and surgeons is offset somewhat by a relatively low count of PAs per-capita (32 per 100,000 population), which is considerably less than the cohort average (47 per 100,000 population) and nearly half that of the neighboring Baltimore MSA (61 per 100,000 population).
Nurses (registered nurses and nurse practitioners)
Registered nurses (RNs), the largest single HCC group of the providers in this analysis, had a direct impact on COVID-19 diagnosis and treatment during the pandemic. One of the chief tools in health policymakers’ toolkits was the expansion of the RN workforce, whether through accelerated graduation of nursing students or reintroduction of previously retired nurses. Nurses played pivotal roles across nearly every COVID-19 treatment, including in the most life-threatening ICU situations. Policymakers expanded nurses’ ability to provide COVID-19 treatment through similar methods used for increasing the available supply of PAs (e.g., making it easier to practice across multiple states).[9]
There are almost 4 million actively licensed RNs in the U.S. Of all actively licensed RNs, 3.3 million are employed in the nursing field, 2.7 million of whom are involved in patient care. The density of RNs and advanced practice RNs (APRNs) per 100,000 population varies across states. In 2018, the South Atlantic region of the U.S., which contains the Washington MSA, had 682 nurses with patient care responsibilities per 100,000 population. The Washington MSA (682 RNs per 100,000 population) falls well short of the cohort average (882 per 100,000 population). In fact, the Washington MSA trails each MSA in the cohort except Atlanta (646 per 100,000 population). Nearby Baltimore (1,135 RNs per 100,000 population) and Philadelphia (1,153 per 100,000 population) have nearly double the population-adjusted supply of nurses relative to the Washington MSA.
This disparity underscores the importance of evaluating larger regions such as MSAs or commute zones rather than just looking at Washington. According to 2018 Bureau of Health Workforce data, the District’s supply of nurses (1,841 per 1,000 population) is considerably larger than the nationwide average (1,206 per 1,000 population). State-level data showing high rates for MD and VA masks the fact that parts of MD and VA have much higher RN counts than the cities just outside of the Washington MSA. Washington, D.C. itself enjoys a high supply of health care training programs and provides ample incentives to retain HCCs, but the events of the last 15 months show the importance of regional health care resilience.
Occupational and respiratory therapists
Occupational and respiratory therapists play more specific roles within the continuum of care than many of the other HCCs discussed. Occupational therapists enable patients suffering from physical or mental health issues to perform in everyday activities, like how to communicate following a brain injury or preparation to return to work after an accident. They work in a variety of settings, including hospitals, homes, and rehab facilities. During the pandemic specifically, occupational therapists work with COVID-19 patients whose health was severely impacted by the virus as well as people adapting to a different level of mobility, resource access, and well-being due to pandemic-related changes. Respiratory therapists conduct clinical interventions to improve patients’ breathing when they suffer from chronic obstructive pulmonary disease, chest trauma, pneumonia, asthma, and other diseases that impact a person’s ability to consume oxygen. During the pandemic, they often worked with the most severely sick COVID-19 patients, helping them to breathe.
The Washington MSA falls short of its comparative cohort for population-adjusted supply of both occupational and respiratory therapists, though the range of estimates is similar across all MSAs.
Other Allied Health Professions
As those infected with COVID-19 are increasingly treated from home (at least relative to the pandemic peak that saw ICUs at capacity), home health providers become ever-more central to adequate healthcare delivery. Coupled with medical assistants, who provide valuable COVID-19 care such as vaccine administration, home health aides and other allied health professionals show how an adequate workforce depends on strength of the care continuum.
Research specifically looking at the adequacy of the Washington region’s allied health workforce is scarce. Still, national and state-level studies of health professional shortage areas (HPSAs) show that the Washington MSA’s primary care settings – where allied health professionals are an integral part of care delivery – are vulnerable to an undersupply of providers. Averaging across Washington, D.C., Maryland, and Virginia, less than half of health care need is met; the District itself is in the weakest position of the three with just more than one quarter of its need met according to June 2021 data.[10]
Allied health workforce experts have indicated that “Americans will be returning to their health care providers’ offices,” which will “undeniably lead to a huge spike in demand for [allied] health care workers… who help keep the health care system running.”[11] A chief concern cited is the contraction of non-essential health care jobs during the pandemic coupled with the relatively low pay seen in some allied health occupations.[12] This scarcity could be exacerbated by the potential that allied health professionals may depart for higher-paying occupations, both within and outside of the healthcare field, or leave the workforce altogether.
Scarcity will impact a variety of health care settings, as allied care professionals work in a multitude of environments. For example, while respiratory therapists work mostly in hospital settings (82% of RTs according to Bureau of Labor Statistics data), medical assistants are much more varied (just 15% work in hospitals, with 57% working in physicians’ offices). Data on home health aides is more scarce, but a shortage would make it increasingly difficult for those in need of at-home care to find it.
The Washington metro area falls short of its peers for supply of both allied health professional types. While comparable to neighboring region Baltimore and two southern geographies, Atlanta and Dallas, the Washington MSA trails each Northeastern MSA by at least three-fold. The overall cohort average (1,114 per 100,000 population) has double the home health aides that the Washington MSA reported in 2020 (561 per 100,000 population), and 128% of the Washington region’s supply of medical assistants (882 per 100,000 population compared to 682).
Certification, and thus quantification, of allied health professionals varies considerably by state, and even by locale. It is hard to precisely estimate the number of allied health professionals given issues of self-reporting (i.e. individuals employed in other professions choosing to self-report as home health aides, or conversely home health aides identifying with another occupation).[13] However, assuming that all estimates have similar biases in the identification of allied health professionals, the data still yields a significant gap between the D.C. region and neighboring jurisdictions.
Conclusion
The COVID-19 pandemic has shown how important an adequate workforce is to the delivery of high-quality health outcomes. Indeed, ensuring an effective supply of health care clinicians is critical beyond current pandemic conditions as the ongoing effects of the coronavirus and pre-existing health needs (primary care and beyond) remain. The analysis in this article underscores the difference between looking at the roughly 700,000-person District of Columbia and the roughly 6.3 million Washington metropolitan area residents. Washington’s myriad physician, nursing, therapist, and allied health training programs all-but-ensure that the District will have a large pipeline of providers. The broader region, meanwhile, falls short in a number of critical provider types, many of whom have been integral to COVID-19 response. Further analysis could yield the dynamics underlying these descriptive facts and illuminate how to go about shrinking the gap.
In the next article in this series, using an original dataset created collected from the D.C. Department of Health and other stakeholders, we will zoom in on the healthcare workforce within the District specifically, how it has fluctuated over time, and specifically the composition of the healthcare workforce during the spring of 2020.