The future of health social work

See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/9065072 The Future of Health Social Work Article  in  Social Work in Health Care · February 2003 DOI: 10.1300/J010v37n03_01 · Source: PubMed CITATIONS READS 19 1,117 authors, including: EV Pecukonis Margarete Parrish University of Maryland, Baltimore Bournemouth University 39 PUBLICATIONS   459 CITATIONS    12 PUBLICATIONS   82 CITATIONS    SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: Teenage Pregnancy and Parenting among Foster Youth View project All content following this page was uploaded by Margarete Parrish on 19 May 2014 The user has requested enhancement of the downloaded file Tai ngay!!! Ban co the xoa dong chu nay!!! 16990024092171000000 The Future of Health Social Work Edward V Pecukonis, PhD, MSW Llewellyn Cornelius, PhD, MSW Margarete Parrish, PhD, MSW ABSTRACT The practice of social work in health care is at a critical juncture, and faces an uncertain future The authors provide an overview of the challenges facing social work practice within the health care setting, as well as recommendations for enhancing social work practice and education Challenges discussed include economic factors, demographic changes, and technological advances influencing the practice of social work in health care The need for a proactive stance among social work professionals and educators is promoted The proposed changes are intended to stimulate discussion and an exchange of ideas needed to maintain Social Work’s relevance and integrity in the evolving health care delivery system [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH E-mail address: Website: © 2003 by The Haworth Press, Inc All rights reserved.] KEYWORDS Social work, health care, health care delivery systems, organization, social work education THE CHALLENGES FACING SOCIAL WORK IN HEALTH CARE SETTINGS The practice of social work in health care faces an uncertain future Like other health professions, social work is being compelled to rethink Edward V Pecukonis and Llewellyn Cornelius are Associate Professors, and Margarete Parrish is Assistant Professor, School of Social Work, University of Maryland, 525 West Redwood Street, Baltimore, MD 21201 Social Work in Health Care, Vol 37(3) 2003 http://www.haworthpress.com/store/product.asp?sku=J010  2003 by The Haworth Press, Inc All rights reserved 10.1300/J010v37n03_01 SOCIAL WORK IN HEALTH CARE its mission and to identify the practice components needing change Many of the challenges, such as managed care, currently influence social work practice, while others, such as genetic engineering, are imminent and will revolutionize how health care is delivered in this country As a profession, we must prepare for these changes while remaining connected to the integrity of our profession In general, the following four factors will have dramatic influence on the practice of social work within the health care setting: (1) The organization and delivery of health services, (2) The supply of health care providers, (3) The changing demographics of the population and (4) Advances in genetic engineering This paper will explore and summarize these trends and suggest a course of action to address these challenges THE ORGANIZATION AND DELIVERY OF HEALTH CARE Most of the recent changes in health care delivery are the result of cost containment strategies that can be lumped under the rubric of managed care The acute care hospital, once the crucible of health care delivery, has been restricted and reorganized by strategies to reduce the cost of health care in this country As predicted in the early 1980s by Jeff Goldsmith (1981) in “Can Hospitals Survive?” the bulk of health care service is now delivered in ambulatory care centers whose primary function is to control the cost of diagnosing and treating disease In fact approximately 98% of all medical encounters now occur in non-hospital settings (Berkman, 1996) Traditional Hospital Systems: The Way of the Dinosaur Related to the shift from hospital to community-centered care is the fact that many large hospital systems have merged with others, diminished in size, or been dismantled Occupancy rates during the past fifteen years have on the average been below 70% for the majority of hospitals in our health care system (AHA, 2001) In addition, hospital utilization, as measured by admissions, lengths of stay and surgeries performed, has decreased dramatically (AHA, 2001) In response to the decline in hospital admissions and length of stay, over 650 community hospitals within the United States closed their doors between 1987 and 1999 (DHHS, 1999) During those same years many of these hospitals became dependent on federal subsidies for indigent care and graduate medical education Today, these sources of Pecukonis, Cornelius, and Parrish funding are less reliable For example, since 1965 the Medicare and Medicaid programs supported graduate medical education in teaching hospitals Prior to the passage of the Balanced Budget Act of 1997, Medicare and Medicaid provided over $8 billion per year in support of these teaching hospitals (Committee on Pediatric Workforce, 2001) These funds were principally used to support residency-training programs and provide health care services to indigent populations This trend along with more recent legislation to reduce the oversupply of physicians is expected to have a negative impact on the amount of health care services provided to indigent populations by teaching hospitals (Modern Healthcare, 1999; Debas, 1997) Bellandi (2000) suggests that the Medicare and Medicaid spending constraints enacted under the Balanced Budget Amendments of 1997 promoted hospital layoffs, and reductions in service and hospital closures In 1998 alone, 28 urban and 15 rural hospitals were closed (Bellandi, 2000) Still others speculate that the survival of the teaching hospital will be determined by the movement of outpatient care to managed care organizations (Rovner, 1999; Debas, 1997) Regardless of the cause, it is clear that hospitals across this nation are closing their doors In an effort to survive, many hospitals have developed creative marketing strategies For example, some community hospitals faced with occupancy problems have merged with larger medical systems or academic institutions Such steps have been taken with the hope of monopolizing market share within a specific geographic region Another strategy, to fill the empty beds, has been to develop “centers of excellence” that promise specialized service at a good price, (i.e., cardiac-care centers, women’s health programs, etc.) These strategies, although promising in the short run, will confront the same long term difficulty of, “How we fill the beds” when more and more health care is being delivered on an outpatient basis? Managed Care The past 15 years has witnessed the industrialization of health care with annual costs approaching $1.2 trillion or approximately 14% of the United States Gross National Product (HCFA, 1999) Currently, an estimated 90% of these medical expenses are handled by MCO’s or managed care organizations (U.S Census Bureau, 2000) Despite consumer backlash and demands for more provider accountability, managed health care is here to stay as this system is now encased within a business infrastructure that will be difficult to dismantle 4 SOCIAL WORK IN HEALTH CARE Health Care Models of Practice Concurrent with the changes in the organization of health care, the model of health care delivery has changed during the past decade Historically, an acute care model was utilized, where the inpatient health care system was discretely focused on the physical factors contributing to the acute medical condition This model depicts illness as an isolated event, with the patient being hospitalized, treated and discharged “The role of the Social Worker in this framework was focused on discharge planning, reducing lengths of stay and (eliminating) rehospitalization” (Berkman, 1996, p 3) Within our present environment, the practice of discharge planning (historically implemented by social work), has been narrowly redefined and now often completed by other health professions such as nursing Without social work input, discharge planning has become more of an event rather than a comprehensive process Thus, we have moved away from the psychosocial assessment model, unique to social work practice, to a brief discussion of medication management and follow-up appointments Although the social worker has attempted to protest and resist this loss of role in discharge planning, perhaps we need to ask ourselves if this is a battle we want to wage given the present trend towards community-oriented care The current health care delivery model reflects a complex system of patient care that addresses patient needs along a comprehensive health continuum–ranging from primary prevention to chronic disease management This “health continuum model” assumes that a patient’s hospitalization and discharge is only one brief aspect along a continuum of care Today, the majority of health care service is delivered and managed in ambulatory settings Perhaps this is where we should direct our energies when rethinking our roles in the evolving health care setting THE SUPPLY OF HEALTH CARE PROVIDERS The practice of health social work is influenced not only by changes in the organization and delivery of health services, but also by the availability of health providers For example, there are approximately 670,000 physicians in the United States (AMA, 2001) An additional 67,000 students are in medical school (Barzansky et al., 2001) with an additional 97,000 residents completing their specialty training each year (Brotheton, 2001) These numbers suggest an ever-increasing supply of physicians, who typically prefer specialty focus to primary care practice Debas Pecukonis, Cornelius, and Parrish (1997) indicates that specialty physicians have represented the largest increase in practicing physicians since 1965 For example, the number of specialists rose from 56 per 100,000 population in 1965, to just over 123 per 100,000 population in 1992 The supply of physicians has been relevant to health social work for two reasons: (1) The potential for improving access to care for the indigent and (2) the impact of social work on medicine’s monopoly in providing mental health services In regards to the supply of physicians and access to care, the challenge has been not so much the supply of physicians but their distribution Both the federal government and American Medical Association have been trying to find ways to encourage physicians to practice in underserved areas i.e., inner city and rural areas In terms of mental health services, it is clear that other health care providers (e.g., nurses and primary care physicians) have incorporated psychosocial interventions into their practice reducing the monopoly over these services that psychiatrists once enjoyed In addition, social workers have been seen as a cost effective substitute for psychiatrists in the provision of selected mental health services Psychiatry Although psychiatry has attempted to re-affiliate itself with the medical community since the early ’80s (through attempts at re-medicalizing psychiatry) this specialty faces a major crisis With much of first-line psychiatric assessment and care now being handled within the primary care setting (by family physicians and pediatricians, or by non-medical providers such as social workers and psychologists) the psychiatrist often assumes a consultive role by only seeing patients that cannot be adequately treated or managed in other settings It is not surprising that most psychiatric residencies continue to have great difficulty filling training slots For example, between 1988-1998 residency programs in psychiatry showed a 42.5% decrease in filling available training spots (NRMP, 1999) Medical students appear less and less interested in pursuing careers in psychiatry, where income potential continues to be challenged by managed care Medical students leaving school with significant loan indebtedness are opting for higher paying specialties In fact, reimbursement for psychiatric services is far less than any other branch of medicine (Blackmon, 1993) Limited reimbursement for psychiatric care may not only be reflected in the differences in compensation relative to other medical specialties, but may also be influenced by the population’s growing preference for social SOCIAL WORK IN HEALTH CARE work services For example, Fall, Jennings and Eberts (1999) report that 33 percent of mental health consumers surveyed were seen by social worker’s compared to 20 percent for psychiatrists, 18 percent for psychologists, 12 percent for master level professional counselors and percent for doctoral level licensed professional counselors CHANGING DEMOGRAPHICS IN THE UNITED STATES A third tier of factors influencing the delivery of health social work considers the changing composition of the U.S population The changing demographics of the American population have significant practice implications for social workers During the next 15 years the overall population in the United States will continue to age and increase in ethnic and cultural diversity First, Americans are living longer By 2025 the average life expectancy will be 82 years for women and 76 years for men, with more than 150,000 people surviving past the age of 100 (U.S Census 1999) Baby boomers make up 47% of today’s work force, with the majority of these individuals eligible for retirement around the year 2020 (U.S Census, 2000) America is also becoming ethnically diverse Today, approximately 82% of the population is white However, this percentage is decreasing and will level off to about 79% in the year 2015 At that time, it is anticipated that Asians will make up 5%; African Americans 13% and Latinos will compromise approximately 15% of the U.S population By 2050 the U.S population will double with minority groups comprising nearly 40% of U.S citizens (U.S Census, 2000) The aging and diversification of our country have implications for social work practice that will demand the development of practice methods directed at empowering the elderly and integrating culturally diverse populations In addition, the social work profession will be in a position both to advocate for and monitor whether clients are receiving culturally competent services Health Promotion and Disease Prevention Along with changing demographics will come changing health care needs With increased numbers of older adults in the population there will also be increases in the proportion of Americans with chronic illness This type of chronic illness will be determined by a host of factors Pecukonis, Cornelius, and Parrish including a persons social and physical environment, their psychological make-up, genetic predisposition, access to health care and most importantly lifestyle choices Health promotion and disease prevention will become key interventions for improving health and limiting the economic burden of chronic disease Interestingly, the number of people suffering from chronic disease (such as hypertension or diabetes) is changing, and is expected to increase almost 14% by 2010 Consequently, the number of Americans suffering from an ongoing and chronic health problem will approach 100 million or 35% of the entire population within the next decade Health and Behavior Some may find it surprising that the leading cause of death in the United States remains cardio-vascular disease (Hoyert et al., 2001) It has been widely reported that the five leading risk factors for developing cardio-vascular disease are: diet, obesity, sedentary life style, smoking, and hypertension (NHIS, 2001) Interestingly, all of these risk factors reflect behaviors or life style choices Thus, the leading cause of death in this country is not some exotic disease of unknown origin, but rather common everyday behavior We not need a degree in chemistry, pharmacology or medicine to recognize or treat these risk factors Changing behavior represents an area of social work expertise A social worker’s expertise in changing risk behavior is also relevant when we consider other nation-wide health problems, such as teen pregnancy, AIDS, drug dependence, domestic/community violence, and obesity Given that behavior choice is the primary reason for these health conditions, effective interventions must be crafted from behavioral change strategies The prevention and treatment of these health problems involves changing behavior, representing an important opportunity for social work THE GENETICS REVOLUTION One of the factors that can become both a burden and opportunity for health care delivery in this country is the evolving genetics revolution On one hand genetic engineering will lead to an increase in new treatment that may buffer the effects of acute or chronic illness Conversely, expensive genetically engineered medicines or procedures may not be available to all segments of our society The ethical and scientific issues SOCIAL WORK IN HEALTH CARE are profound Recently, Richard Hayes, (in Williams, 2000) the coordinator of the New Human Genetic Technologies, wrote: “We are fast approaching what is arguably the most consequential technological threshold in all of human history: the ability to directly manipulate the genes we pass on to our children” (p.11) Development of these technologies will change life on this planet, as we know it In 2001 the Human Genome Project was completed and now provides us with a map of our genetic structure These findings will lay the groundwork for advances in biotechnology that will revolutionize health care practice Claims for cures professed by these researchers resemble science fiction and predict everything from genetically engineered medications to children whose genes are selected by parents from on-line catalogues Some even predict the evolution of a genetically enhanced elite that will polarize common humanity, as we know it (Hayes, 2000) Needless to say, the ethical concerns will be profound and require careful thought and discussion As a profession we will need to infuse ourselves into these discussions of how advances in biotechnology will be used by the corporate sector In general, two types of genetic engineering are being developed: Somatic and Germ line enhancement It is important to understand the differences between these types of genetic engineering since they have implications for social work practice For example, in Somatic enhancement, defective genes in the body are repaired and cure disease or enhance physical attributes such as body weight, improving memory or growing hair for a balding man Here the goal is to cheat the aging process and perhaps extend human life by repairing damaged or aging organs/systems within the body Most importantly, these genetic modifications are not passed on to future generations Conversely, in Germ-line enhancement the genes associated with reproduction (egg and sperm or embryo) are systematically changed Unlike somatic treatments, Germ line genetic enhancements are passed on to future generations Clearly, this type of genetic engineering has profound ethical and moral considerations for both society and the health care professions In general, with these advances comes the unsettling questions of who decides what will be engineered and who will receive these enhancements Although still experimental, considerable research is focused on developing genetically engineered medications For example, in the past the only way to obtain insulin for human consumption was from animals Today, cloning the human gene that carries the instructions for creating insulin can actually produce insulin Likewise, the human growth hormone can now be produced in significant quantities via ge- Pecukonis, Cornelius, and Parrish netic engineering The day will come when precision drugs for specific disease states will be custom made, based on the individual’s unique genetic structure and history These drugs will be specific in their actions and have little or no side effects IMPLICATIONS FOR SOCIAL WORK Given the influence of these variables on health care, what are the implications for social work? How should we plan? What opportunities should we pursue? Whatever path our profession chooses, it is imperative that we define the nature of our expertise and clearly articulate these roles both to the public and other health professions We must be precise about how we can contribute to this new and evolving health care arena It is important to define these roles, own them, promote them, advocate for them, and above all protect them Our traditional roles within the health care setting may become obsolete as we evolve and adapt to our changing health care setting This means rethinking what we do, how we it and why we it Above all, we must be proactive in these efforts, becoming advocates shaping practice, education, training, legislation and policy that will serve to solidify and reinforce these evolving roles Social Work Education First, let us consider social work education There are several things that social work education must accomplish during the next 3-5 years: Introduction of the Brain and the Central Nervous System to Curriculum Given the changes that lie ahead, it is imperative that schools of Social Work introduce the importance of the central nervous system and its influence on behavior within their curricula and continuing education programs Historically, Social Work has been steeped in sociological and personality theory Although it is important that these traditions be maintained we must also make room for advances in health science Although we must not abandon our belief in the role of social and psychological factors shaping human behavior, we need to utilize a true bio psychosocial model of social work intervention Thus, we must include the brain and its influence over behavior and emotion within our curric- 10 SOCIAL WORK IN HEALTH CARE ula At the very least we will need to understand human genetics and the role it plays in shaping behavior For example, how many social workers would understand the difference between transcription and translation of RNA? Likewise, how many of our graduate students would understand the notion of gene expression or the human genome? Such material is now common knowledge within high school science curricula but often foreign to graduate level social work students and their faculty Psychopharmacology Advances in biotechnology will compel us to learn pharmacological principles Understanding the structure and function of both psychotropic and other health enhancing medications must become part of the knowledge domain informing our practice of social work Perhaps we should take a lesson from our clinical psychology colleagues, who are making strong inroads to convince the medical community that they too should be allowed to prescribe psychotropic medications In some regions of this country nurse practitioners and pharmacists have already acquired these prescribing privileges Is this a road that we should also be following? Although we know that behavior is not solely determined by genetics and biology, biochemistry is a crucial component in fully understanding, managing and predicting behavior In social work the bio in the biopsychosocial model has been largely ignored We call our selves “social” workers but in the future we will have to be “biopsychosocial workers.” Include Mental Health in Health Sharon Keigher (1999) recently wrote, “I am reminded there still are social workers either so specialized or so disconnected that they presume ‘mental’ is not included in the concept of health” (p 85) Unfortunately, many social workers within the health care setting ignore the role of cognition and emotion as it relates to a person’s health Out of tradition, many schools of social work continue to separate the (medical) health specialization from the mental health specialty Given the changes that lie ahead, it appears critical to reintroduce mental health into the health care setting Health social workers must be competent and comfortable in addressing mental health issues with their clients The Surgeon Generals Report on Mental Health (U.S Department of Health and Human Services (1999)) recommends that health and mental Pecukonis, Cornelius, and Parrish 11 health be seen as interrelated Clearly, chronic health conditions often have significant emotional components affecting their course and outcome As health care social workers we must also advocate for mental health parity In this sense it is important to support both legislation and social policy that will create equity between social work and other mental health providers This request for parity should include enactment of policy promoting commensurate compensation for client care in ambulatory settings as well as allowing social workers to both certify and admit patients suffering from mental illness to psychiatric care facilities These changes will create roles for social workers in emergency rooms and other mental health facilities that require these types of intervention It will also allow the clinical social worker in private practice the opportunity to follow and obtain reimbursement for their services during a client’s inpatient stay Finally, we must also advocate for health insurance parity between health, mental health and substance abuse services This will allow clients greater options in seeking treatment for presenting problems Primary Care Social Workers: Health Promotion and Disease Prevention It is important that social work curriculum address health promotion and disease prevention In a nation where the leading causes of morbidity and mortality reflect life style choices, we must capitalize on our expertise in behavior management We need to develop a new Clinical Social Work specialty in behavioral medicine that focuses on the prevention of diseases and promotion of health for the individual, family and community Similarly, just as health care services have left the hospital and moved to the community, so too should the social worker Is it possible to have a social worker in every primary care provider’s office? Social workers are ideally suited to filling a clinical need within these practices and will it cost effectively Primary care physicians rarely have time to comprehensive interviews, provide education or support to their patients Many physicians are asked to see patients every 15 minutes Patients are run through the office like an assembly line Skills in interviewing or addressing the psychosocial needs of patients are necessarily put to the side As a result physicians are limited in their ability to provide emotional support, health education, and coordination of care for their patients The cost effective solution is to allow Social workers to 12 SOCIAL WORK IN HEALTH CARE fill this need Social workers possess skills to coordinate education groups with clients that have multiple health concerns Social workers are skilled and work effectively with high-risk patient groups such as pregnant or parenting teens, drug abusers, and survivors of domestic violence Social workers are ideally suited to provide support to clients with new onset health concerns such as cancer, AIDS, diabetes or hypertension and assist them in managing these illnesses In addition, social workers could play a role in the management of patients with chronic diseases such as Alzheimer’s, MS, traumatic brain injury, schizophrenia, etc In support of these social work tasks we must also be willing to move away from our dependence on federal and local government funding and create inroads into the private health care sector We must become entrepreneurs–a thought that is often is avoided by the social work profession Community Based Family Health Centers Given these anticipated changes in health care, it is logical to envision the evolution of community based family health centers These family-based service centers could be created within an environment of interdisciplinary practice and offer comprehensive service to families residing within a specified geographic location Although the major goal of this type of center would be to provide support to community members who are managing health concerns, they should not be confused with a health clinic, where the primary goal is the provision of physician-based services This would not be the goal within a social work centered family health program Instead, the clinical social worker and community organizer would work side by side to assist families in managing their health and the systems that influence this care Such facilities could provide family access to: support, information and education, disease management, brokering of home based services and monitoring, self-help programs, health promotion, counseling, discharge planning and implementation, case management, decision making around ethical issues, exercise, smoking cessation programs, domestic violence interventions, substance abuse treatment, as well as blood pressure and other health care monitoring, etc Such a setting would provide a place where the health consumer is empowered to be a partner in the health care team, rather than a passive recipient of care Pecukonis, Cornelius, and Parrish 13 Ethics Consultants and Advocacy for the New Health Consumer As Richard Hayes (2000) suggests, “We need national and community leaders, activists, journalists, scientists, scholars and other citizens to inform themselves, in short order, about the critical aspects of the new human genetic technologies and to join together to begin building nothing less than a new social movement” (p 3) The emerging focus within the health care system on promoting the voice of the consumer fits well with the social work skill of advocacy Many clients will not understand the advances in medical technology and in genetic engineering Someone will need to educate and assist them in developing strategies for negotiating aspects of their care CONCLUSION Only a decade ago, one could pick up any newspaper, turn to the want ads and view advertisements for cash register repair technicians or switchboard operators Today, advances in technology have made these jobs obsolete This caution is relevant to the social work profession Beware If we not adapt to the changing times we too may become obsolete If we are not thoughtful about our plan of action, health social work as a career path may go the way of the dinosaur If we are to survive we must identify the dangers and opportunities One danger is that health social work may become consumed by or merged with other health professions such as nursing, public health or health administration Although we must adapt to the changing times, we must not give up our social work methods and values We must avoid such mergers We must also remember that we are not MBAs, nurses, lawyers, bill collectors, policeman or social control agents for the medical corporation whose policies and directives often go against the values of our profession by dehumanizing health care delivery It is important for us to remember that self-determination is a social work value The valuing of each person equitably is our goal as social workers, not necessarily the valuing of the least costly intervention Our values tell us to deliver services that are effective, compassionate, accessible and timely We are part of a society that spends over $1 trillion annually on health care, yet one-sixth of our population have limited or no access to this system Our nation’s health care costs now approach 15% of our country’s gross national product This is a vast sum of money How can we as social 14 SOCIAL WORK IN HEALTH CARE workers justify the premise that it is not enough money to pay for a system that includes all Americans? Promoting the management and restriction of health services from those in need is often incongruent with the values of the social work profession We must neither cheapen social work, nor overlook the values that called us to this profession We must look for ways to shape and influence the changing health environment in a manner that is consistent with our professional values The social work profession is crucial to the evolving health care setting Our ethical principles of service, social justice, dignity, and self-determination within the matrix of human relatedness are central to the health care debate We must remember that regardless of what has happened to the management of health care, the problems faced by real people in the real world remain People continue to get sick, suffer and die from their maladies They continue to engage in behaviors that negatively influence their health and continue to require medications and access to appropriate medical care They still have the need to be treated with compassion and understanding and they certainly need access to someone who will stand by them, as they grow older Above all, they continue to need a voice that will advocate and fight for them in the face of adversity and oppression That voice is and has been and should remain the voice of social work Manuscript Received: 04/22/02 Accepted for Publication: 11/25/02 REFERENCES American Hospital Association (2000) Survey of Hospital Occupancy Rates 1991-2000 Chicago, Ill Anderson, G., & Poullier J (1999) Health Spending, Access & Outcomes: Trends in Industrialized countries Health Affairs 18, No Barzansky, B., & Etzels (2001) Education Programs in U.S Medical Schools: 2000-2001 JAMA 286: 1049-1055 Bellandi, (2000) More Hospitals Close Modern Healthcare Vol 30 (#33): 22 Berkman, B (1996) The Emerging Health Care World: Implications for Social Work Social work, Vol 41, 541 Blackmon, W.D (1993) Are psychoanalytic billing practices ethical American Journal of Psychiatry Vol 47 (#4): 613-621 Brotheton, S., Simon, F., & Etzel, S (2001) U.S Graduate Medical Education: 2000-2001 JAMA 286: Committee on Pediatric Workforce 2001 Financing graduate medical education to meet pediatric workforce needs Pediatrics Vol 107 (#4): 785-789 Pecukonis, Cornelius, and Parrish 15 Debas, H.T (1997) Manpower and training in the 1990s American Surgeon Vol 63 (#10): 847-849 Department of Health and Human Services (2001) Hospital Closure: 1999 Office of the Inspector General, United States of America, OEI-04-01-00020 March Fall, K.A., Levitov, J.E., Jennings, M., Eberts, S (2000) The public perception of mental health professionals: An empirical examination Journal of Mental Health Counseling Vol 22 (#3):122-134 Galloro, V (2001) Shaken by shortfall Modern Healthcare Vol 31 (#36):14-15 Goldsmith, J (1981) Can Hospitals survive? The new competitive Health Care Market Homewood, IL: Down Jones-Irwin Hayes, R., (2000) The Politics of Genetically Engineered Humanity Loka Alert 7:2 May Healy D (1997) The Antidepressant Era Harvard University Press Boston, MA Health Care Financing Administration (1999) Office of the Actuary: National Health Statistics Group, U.S Department of Commerce, Bureau of Economic Analysis Washington, D.C Health Resources Services Administration (2001) United States Health Workforce Personnel Factbook Available Online (accessed 12/19/01): Holohan, J., & Cohen J (1990) Nursing home reimbursement Generations Vol 14 (#2): 59-64 Hoyert, D., Arias, E., Smith,B., Murphy, S & Kochanek K (2001) Deaths: Final Data for 1999 Vital Statistics Report 49:8 Hyattsville, Maryland, National Center for Health Statistics Keigher, S (1999) Including Mental in Health Social Work Health & Social Work 24:2, p 85 Krach, C (1999) Centenarians in the United States United States Census Bureau, Population Projection Branch Washington, D.C Modern Healthcare (1999) Teaching hospital split over payment proposal Modern Healthcare Vo 29 (#4): 26-27 Rovner J (1999) U.S Insurers will pay tax for training doctors Lancet Vol 353 (#9159): 1166 United States Government Accounting Office (2001) Medicaid and SCHIP States’ enrollment and payment policies can affect children’s access to care Washington, DC: U.S General Accounting Office United States Census Bureau (2000) Current Population Survey Washington, D.C United States Census Bureau (2000) Projected Life Expectancy at Birth by Race and Hispanic Origin, 1999-2100 Washington, D.C United States Department of Health and Human Services (2000) National Health Interview Survey Center for Disease Control, National Center for Health Statistics, Hyattsville, Maryland United States Department of Health and Human Services (1999) Mental Health: A Report of the Surgeon General Available online-accessed 03/08/02 Weissenstein, E (1998) Debt Decision reversed Modern Healthcare Vol 28 (#15):6 Weissman, S (1998) Why HMO’s, the Federal Government and Hospital Prefer a Surplus of Physicians Psychiatric Times 15:5 Williams, P (2000) Dust and Destiny The Nation 271:3 July View publication stats