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PNSSRNOESPAPAEAPCPPCMHRNSAMHSASNFSNMMISUDWRVULong term services and supportMedicare Beneficiary SurveyCMS’s Nursing Home Minimum Data SetMedical Expenditure Panel SurveyAssociation for Addiction ProfessionalsNational Ambulatory Medical Care SurveyNational Board for Certified CounselorsNational Commission on Certification of Physician AssistantsNational Center for Education StatisticsNational Center for Health StatisticsNational Council Licensure ExaminationNational Hospital Ambulatory Medical Care SurveyNational Health and Aging Trends StudyNational Home and Hospice Care SurveyNational Inpatient SampleNational League for NursingNurse midwifeNational Nursing Home SurveyNurse practitionerNational Provider IdentificationNational Plan and Provider Enumeration SystemNational Registry of EMTsNational Survey on Drug Use and HealthAAMC’s 2019 National Sample Survey of PhysiciansNational Sample Survey of Registered NursesOccupational Employment StatisticsPhysician assistantPhysician Assistant Education AssociationPrimary care providerPatient-centered medical homeRegistered nurseSubstance Abuse and Mental Health Services AdministrationSkilled nursing facilitySociety of Nuclear Medicine and Molecular ImagingSubstance use disorderWork relative value unitix

I. IntroductionThe Health Workforce Simulation Model (HWSM) is an integrated microsimulation model thatestimates the current and future supply of and demand for health care workers by occupation,geographic area, and year. Demand projections also are modeled by employment setting. HWSMis designed to produce national and state-level workforce projections. Starting in 2019, HWSMmodels demand at the county level so that projections can be aggregated to report demand bymetropolitan versus nonmetropolitan location. HWSM models the implications of changingdemographics on health workforce supply and demand, as well as trends and policies affectingcare use and delivery.The purpose of workforce modeling is to quantify the implications of trends affecting healthworkforce supply and demand, and whether full-time equivalent (FTE) a supply will be adequateto meet demand. The gap between supply and demand is often referred to as a shortage ifdemand exceeds supply, or as a surplus (or excess capacity) if supply exceeds demand. Suchinformation promotes efficient allocation of resources regarding the number of health workers totrain and whether jobseekers should enter a particular health occupation or specialty.Workforce demand is defined as the number of health workers required to provide a level ofservices that will be utilized given patient health-seeking behavior and ability and willingness topay for health care services. Training more health workers than required (i.e., excess capacity)can have detrimental consequences for providers seeking fulfillment in their career. Training toofew health workers (i.e., shortage) reduces access to care—especially for historicallyunderserved and vulnerable populations—and contributes to burnout among existing healthcareworkers. As discussed later, demand is different from need. Demand reflects the level of carethat people are likely to use in the absence of supply constraints while need is a clinicaldefinition.Starting year supply is estimated based on the number of people active in the workforce, whichconsists of people working and people actively seeking employment. It reflects estimates ofhours worked to calculate FTEs. Estimates of active supply and FTE supply generally are lowerthan estimates of licensed supply (for occupations requiring a license) or number of trainedaFor modeling, we measure both supply and demand in terms of full-time equivalents (FTEs). Unless otherwise specified throughoutthis report, demand is used synonymous with “FTE demand” and supply is used synonymous with “FTE supply.” An FTE has beendefined as working 40 hours per week since the year 2017. Prior studies used average weekly hours worked within a profession todefine an FTE, so the definition varied by profession. Hence, estimates of FTE supply will differ from other supply metrics such aslicensed supply or active supply, or estimates that use a different definition for FTE.1

workers (for health occupations that do not require a license.) This is because some individualswho are licensed and trained choose not to participate in the labor force. HWSM models thenumber of individuals trained each year who enter the workforce, so the supply projections areestimates of total number of people trained to provide services. Projections of total peopletrained might exceed total employment for an occupation.HWSM uses a microsimulation approach to supply modeling, meaning that individual healthworkers are modeled with data obtained from: Associations likeo American Medical Association Masterfileo American Dental Association MasterfileNational surveys with a representative sample of health workers likeo American Community Surveyo Health Resources and Services Administration’s [HRSA] National SampleSurvey of Registered NursesState licensure files as availableFor supply modeling, HWSM simulates the current workforce and labor force participationdecisions to project how supply will evolve over time. The projections reflect estimates andassumptions of the annual number and characteristics of newly-trained workers entering a givenoccupation. They also include prediction equations that describe workforce attrition probabilitiesand weekly number of hours worked.While the nuances of modeling differ for individual health occupations and medical specialties,the basic framework used within HWSM remains the same and consists of three components:1) The model for supply of health professionals2) The model for demand for health care services3) The staffing ratios that convert demand for services to demand for health care workers(Exhibit 1)To project the number and characteristics of future health care workers and service users, HWSMsimulated individual-level data based on predicted probabilities estimated from the current or baseyear data. Depending on the predicted probabilities, individual records were simulated to ageforward. The aged individual-level records were then aggregated to obtain the projections bygeographic area. On the service use side, the current utilization rates by individual characteristicswere applied to projected populations at the national and state levels.2

Modeling demand starts with constructing a database that contains characteristics for each personin a representative sample of the population in each county and state over time. Predictionequations model the expected demand for health care services based on each person’scharacteristics like: demographicshealth risk factors including smoking and obesitypresence of diseases such as diabetes and cardiovascular disease, among otherseconomic considerations including whether the person has medical insurance and level ofhousehold incomeDemand for health care services is then used to model health workforce demand.Exhibit 1: HRSA’s Health Workforce Simulation ModelHWSM models future supply and demand under different scenarios reflecting trends andassumptions about key supply and demand determinants. All scenarios reflect changing3

demographics. For example, supply accounts for aging of the health workforce and differencesbetween men and women in labor force participation. Demand accounts for population growthand aging. Additional supply scenarios model the sensitivity of projections to trends in early ordelayed retirement, and training more or fewer health workers compared to current levels.Additional demand scenarios reflect estimates of how patient health care use might change ifbarriers to accessing care were removed, or how demand and/or supply might change as a resultof developments and trends in our evolving healthcare delivery system.Demand for health workers is based on projections of the level of health care services thatpatients will use and how the staffing is configured to deliver care. The “Status Quo” demandprojections extrapolate current national health care use and delivery patterns by personalcharacteristics to the state and county level a projected populations into the future. Thesehypothetical future populations’ demographics, disease prevalence, economic factors, and otherhealth risk factors reflect the expected changes in these factors across geographic areas and overtime. Therefore, demand estimates for each state reflect what demand would be for thepopulation in that state if each person used the national average level of care for a like person. Alike person is one with the same demographics, same health risk factors, same presence ofdisease, same rurality b of residence, and same household income and insurance status.Extrapolating current national patterns of care use and delivery does not imply that currentpatterns of care use and delivery are optimal or even efficient. This scenario simply reflects therealities of the current health care system and economic considerations including: medical technologyhealth policyinsurance coverageprices for health care servicesreimbursement rates to providerscultural normsother factors that affect care use and deliveryaFor estimation by metropolitan/nonmetropolitan designation in each state, county-level estimates were generated for oral healthprofessions and for general surgeons in 2019 and for primary care providers, women’s health services providers, and behavioralhealthcare workers in 2020.b Before 2019, this was metropolitan statistical area (MSA) versus non-MSA; after 2019 this was stratified by the sixclassifications in NCHS’s Urban Rural Classification System.1 In this classification scheme, counties are classified (from highestto lowest population density) as “Large central metro,” “Large fringe metro” (which NCHS notes is a proxy for suburban),“Medium metro”, “Small metro”, “Micropolitan”, and “Non-core”.4

Status Quo projections of future demand indicate the number and occupation/specialty mix ofhealth workers that would be required if we continue to use and deliver care according to currentpatterns. Alternative scenarios quantify future demand for health workers if care use and deliverypatterns change. Comparison of Status Quo to alternative demand scenarios provides insights onthe contribution of population growth and aging to future demand for health workers. This can becompared to the contribution of other factors that might change how care is used or delivered(for example, if dental schools started training more dentists or population health programsimproved their patients’ overall health).Current health care use and delivery patterns reflect the current supply of health workers. Hence,for many occupations modeled using HWSM, FTE national demand equals national supply in thebase year. This approach is common across health workforce models.2 In HWSM, there areseveral occupation groups where national demand is calculated to be higher than national supplyin the base year—primary care physicians, psychiatrists, and general surgeons. For theseoccupations, there is great concern of national shortfalls. There is also external evidence ofsubstantial under-supply in many geographic areas as corroborated by the HRSA’s efforts todefine health profes

The National Center for Health Workforce Analysis (the National Center), within the Bureau of Health Workforce, informs public and private sector decision-making on the U.S. health workforce by expanding and improving health workforce data and its dissemination to the