Journal of Community Health Vol. 4, No. 2, Winter 1978
T H E F O R M A T I O N AND E V A L U A T I O N OF A GRADUATE PROGRAM IN H E A L T H A D M I N I S T R A T I O N W I T H I N A MEDICAL SCHOOL J o h n E. Kralewski, Ph.D., and J e f f r e y C. Bauer, Ph.D.
ABSTRACT: Several aspects of the program in health administration that was established in 1968 by the faculty of the University of Colorado School of Medicine are described. Based on the premise that knowledge about the organization and the delivery of health services had not kept pace with the advances made in the scientific foundations of medicine, the program was designed to provide training in management, accounting, economics, medical care organization, quantitative methods, and in the other skills required for health administration. The results of a survey to identify the extent to which the program's graduates have fulfilled the original objectives are presented, including a description of the graduates' backgrounds and current job situations. The lessons learned from five years' experience teaching health administration within a medical school are also reviewed. In 1968, the faculty o f the University o f Colorado School o f Medicine voted to establish a Division o f Health Administration within the D e p a r t m e n t o f Preventive Medicine. T h e division was to p r e p a r e administrators for work in the health field and to conduct studies dealing with the organization and delivery o f health services. In exploring ways to i m p l e m e n t the educational goal, the faculty concluded that traditional g r a d u a t e programs, which p r e p a r e d students for one specific institution, such as a hospital or a health d e p a r t m e n t , limited the graduates' career mobility and caused them to perceive their roles f r o m a r a t h e r narrow perspective. For these reasons, a master's d e g r e e p r o g r a m in health administration was established to p r e p a r e administrators who would seek and p e r f o r m administrative roles within the broad range o f existing and developing health care organizations. As a secondary goal, the p r o g r a m was also p l a n n e d to provide its nonclinical orientation to the students in clinical training p r o g r a m s at the medical center.
CURRICULUM
T h e c u r r i c u l u m was p l a n n e d so that all students would complete a core o f courses in basic m a n a g e m e n t principles, organizational behavior, managerial decision making, p r o g r a m planning and evaluation, quantitative methods, e c o Dr. Kralewski was Professor and Director of the Division of Health Administration, at the University of Colorado School of Medicine, 4200 E. 9th Avenue, Denver, Colorado 80262. He is now assistant to the Vice President, Health Sciences, and Professor and Director of the Center for Health Services Research at the University of Minnesota, Minneapolis. Dr. Bauer is an Assistant Professor in the University of Colorado, School of Dentistry. 150
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nomics, public health, and the sociopolitical aspects of health care. After completing these required studies, students select skill-area courses and field experiences that will broaden their exposure to the health care organizations within which they hope to begin their careers and that will provide them with the skills necessary to function effectively within these organizations. Such career environment areas include hospitals, planning councils, medical group practices, mental health centers, and neighborhood health programs. Skill-area coursework includes financial management and information systems, planning, evaluation, and policy analysis. Students normally spend two academic years in completing the program. A three-month summer field experience between the first and second years and field projects during the second year provide the students with a direct exposure to the specific career environment area elected. For example, a student who wishes to become a hospital planner would concentrate on planning studies, after completing the core courses, and would pursue various field experiences and class projects in the hospital setting. Students usually complete the core coursework during the first academic year; then, with their advisor, they develop a specialized course of study for the second year. Total coursework usually entails 60 to 70 quarter hours of credit.
GRADUATE
SURVEY
To identify the degree to which the program is meeting its original objectives, a questionnaire was mailed to all graduates in early 1975; 75 of the 91 graduates from the program's first five classes returned the questionnarie. Information on most of the remaining graduates was obtained by telephone or personal contact. Data on all students at the time of admission to the program were collected from their admissions records. The data from both the questionnaires and the admission forms were stored in a computer file, which can now be updated and analyzed at regular intervals.
ANALYSIS
In the following discussion, descriptive statistics are used to present the characteristics of the data file; the numerical results of the survey are given in absolute and relative terms. The absolute number of students reported in each category is followed in parentheses by the number as a percentage of the total number of complete responses; in other words, the percentage reports are adjusted for incomplete or inapplicable responses and different subsample sizes. Inferential statistics are not presented because of the small sizes of some subsamples that would have had to be analyzed. Although comparisons of groups for significant differences are not appropriate at the .present time, the information that is currently available indicates many interesting trends, which
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will be analyzed statistically when the number of graduates in the various subgroups has increased sufficiently.
RESULTS
The program's objective of preparing students for a wide variety of administrative jobs appears to have been at least partially achieved. Table 1 presents the responses to the questions that asked graduates to identify their major job responsibility and their institutional settings. The principal job descriptions are listed horizontally, and institutional settings are listed vertically. As shown in the columns, 47 graduates (51.6%) identified themselves as line administrators, 26 (28.8%) of whom were hospital administrators. In the next largest group, 24 graduates (26.7%) gave planning as their principal job responsibility. Of the planners, 9 worked for single hospitals or merged systems that include hospitals, 11 worked for planning agencies, including Comprehensive Health Planning (CHP), and 6 worked for consulting firms. The remaining graduates occupied a braod range of staff and teaching positions, or combined clinical medicine or dentistry with some administrative duties. The relatively high percentage of graduates performing planning roles in hospitals reinforces the program's initial premise that planning is a skill area within health administration rather than a separate discipline. Further, the 11 students who held positions in health planning agencies challenge the notion that graduates of health administration programs would not provide the planning manpower needed for these agencies. The data raise similar questions about the assumption that the prominence of hospitals in the field of health care would cause hospital administration to dominate the graduate programs in health administration and would attract most of the graduates. Fewer than one-third of the graduates have taken jobs as hospital administrators, and only 40% of the graduates are now working in hospital-connected positions. Clearly, the argument that hospital administration, comprehensive health planning, and other administrative roles cannot be linked under one educational rubric, that of health administration, does not hold true in this case. The graduates also worked in many institutional settings, as shown in Table 1. Single hospitals employed 32 graduates (35.2%), while 7 graduates (7.9%) worked in muhihospital health systems. Eight graduates (8.8%) worked for primary care clinics and 6 (6.6%) were employed by a Health Maintenance Organization (HMO). CHP (B) agencies employed 8 graduates (8.8%) and universities employed 10 (11%). The number of graduates in academic positions, 5 (5.5%), was an unexpected finding; all of these graduates were teaching in university medical centers, with 4 of the 5 in departments of community medicine. Regional Medical Programs (RMP), the Department of Health, Education, and Welfare (HEW) (including the Indian Health Service), and health departments and consulting firms employed the remaining 19 graduates.
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O f the 12 graduates with M.D. degrees, 9 listed administration as their primary job responsibility: 6 of the 9 combined administration with clinical responsibilities in group practice settings. The other three listed purely administrative job responsibilities, two in hospitals and one in an HMO; two M.D. graduates were teaching in combination with clinical practices, and one was involved entirely in clinical practice. Planning, either by itself or in combination with clinical practice, was not listed by any of the graduates with M.D. degrees. The number of physicians interested in the graduate program probably reflects the increasing role of the physician administrator. After reviewing the jobs now held by those graduates who were also physicians and the interest expressed by physicians now in the program, two major observations emerge: First, the role of medical directors in hospitals, group practices, and similar organizations is rapidly increasing in importance. This role deals with the quality of care, the relationships of medical staff to administration, the management of the medical component of patient care, and, frequently, the financial arrangements with the medical staff. Second, the physician's role as an administrator of community health programs was evident. In this context, the physician is the chief executive officer of what is often a relatively small program organized to provide health services to a specific population group. Neighborhood health programs, community mental health programs, migrant health programs, and a variety of the recently established rural health systems all fall under this rubric and are some of the programs now being administered by physician graduates of the health administration program. This dimension of the graduate program will likely receive increasing attention, as physicians' services become more highly organized in the future. Salaries
A question on their annual salary was answered by 71 graduates (78%). O f those who responded, 17 (25.4%) earned $15,999 or less per year at their current job. The others included 24 (35.8%) earning between $16,000 and $19,000, 13 (19.4%) in the $20,000 to $23,999 range; 17 (25.4%) were in the $24,000 and above category. As expected, salary levels varied considerably by age, work experience before entering the graduate program, and other credentials (such as the M.D. degree). Overall, four of the eight CHP (B) employees were in the $12,000$15,999 annual income category; one earned less, and the other three were in the $16,000-$19,999 category and none earned over $20,000. O f those employed in HEW or state health departments, five of nine earned above $24,000. In the hospital setting, 4 of 22 earned less than $17,000; 13 earned between $16,000 and $19,999, and 5 were earning above $20,000. (However, only 22 of the 32 graduates employed in hospitals answered the question about salary!) Our data indicate that line administrators are ranked approximately one group above planners in income. At the upper end, seven administrators earn $24,000; no planners are in this group. Although the small number of graduates
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in these categories limits the validity of comparisons, graduates taking hospital jobs generally do earn more than those in nonhospital jobs. Beginning salaries for the last two classes suggest, however, that these salary differentials are narr o w i n g - p e r h a p s indicating a change in supply or demand, or both, for administrators and planners. Student Backgrounds and Employment Analysis Several interesting observations arise from an analysis of the characteristics of entering students and comparisons of this information with postgraduate employment situations. For example, a fairly broad range of undergraduate academic backgrounds was reflected in the students who were admitted to the program: 23 (26.4%) students had undergraduate specialties in the natural sciences. Business and social science majors were ahnost as numerous, with 21 (24.1%) and 19 (21.8%) students, respectively. Other majors included seven (8%) in the humanities, five (5.7%) in pharmacy, three (3.4%) in journalism, two (2.3%) in engineering, one (1.1%) in health administration, and six (6.9%) in other fields. Of the graduates, 22 (24.1%) had also received graduate degrees prior to their admission to the M.S. program in health administration. These advanced degrees included medicine, dentistry, business, and law. In response to questions about additional education since graduation from the health administration program, 31 (35.6%) of the respondents said that they intended to pursue further advanced degree work. However, only one student had actually done so at the time of the survey. The cross-tabulation of undergraduate majors and salary ranges showed that majors in the humanities and the natural sciences had the highest relative numbers of graduates earning $20,000 and above. The figures are 4 (66.7%) and 10 (58.8%), respectively. Only 7 of 18 business majors (38.9%) and 2 of 12 social science majors (16.7%) were in the highest income categories. A cross-tabulation of the students' undergraduate majors and the institutional setting of their current jobs revealed some interesting trends. For example, 16 business majors (76.3%) were working in hospital settings, while natural science majors were distributed relatively equally across all institutional settings. Majors in pharmacy,journalism, and the humanities were similarly scattered. All four of the graduates now working for consulting firms and five of the eight CHP (B) agency employees were social science majors. A comparison between the student's state of residency at entrance and the state where currently employed indicated that 27 of the 44 graduates (62.8%) who were classified as Colorado residents at entrance have remained in the state after graduation. Additionally, 19 of 47 out-of-state residents (40.4%) have also elected to stay in Colorado. Therefore, slightly over half of all students graduating during the past five years reside and work in Colorado. Only 7 of the 47 graduates (15%) from other states had returned to their home states for their current jobs. Although the determination of residency at entrance was based on some subjective criteria, the state where graduate training was completed
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(Colorado) seems to have been more important than their original state of residency as a determinant of geographical location after graduation. This finding may reflect the fact that the field experience that takes place between the first and second years of the graduate program and the field projects during the second academic year cause students to make most of their personal contacts in Colorado. The presumed attractiveness of Colorado as a place to live must also be taken into consideration. In either event, the program clearly has had a substantial impact on the state of Colorado, in terms of providing educational opportunities for students and supplying manpower in the health administration field. Nearly two-thirds of the health planners in the state are graduates of the Colorado program; and two of the three operating HMOs were started by the program's graduates. The major health care programs for underserved rural areas are run by graduates of the program, and nearly 25% of the hospitals in the state, including the university hospital, have graduates of the program on their staff.
PROGRAM SETTING
This discussion would be incomplete without some brief comments about the role of a medical school as the setting for a graduate program in health administration. The University of Colorado program was purposely developed within the medical school to integrate health administrators and physicians during their training and to add the dimension of health administration to the teaching, research, and community service programs of the school. The medical center leaders believed that the school should address organizational and administrative needs and concerns in addition to the traditional clinical and basic science areas. They also believed that physicians would be better equipped to deal with the changing health care system if exposed to health services and health administration coursework during their medical school training. The development of a graduate program in health administration in a medical school will not assure rapid achievement of these goals. Although some academic administrators and students may perceive the need for addiing organizational and administrative courses to the curriculum, many faculty members from the clinical and basic sciences remain unconvinced, and some may feel threatened by this intrusion. The difficulties of achieving respect for health administration as an academic discipline, and for nonmedical faculty as creditable academicians, present serious barriers that sometimes limit program effectiveness in this setting. Many medical schools are exploring the development of graduate prograins in health administration and community health. According to a recent survey conducted by Conrad and Berg, 17 medical schools already report the existence of formal academic programs in these areas (mimeographed report,
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Emory School of Medicine, Atlanta, Georgia). Medical schools or health science centers provide attractive settings for graduate education in health administration; their commitment to excellence in education is widely acknowledged. Their rigorous academic standards, research orientations, and relatively high facultyto-student ratios are well recognized. Health administration programs in these settings provide a bridge between the clinical disciplines and the other academic disciplines that are interested in the organizational and administrative aspects of health care. In this regard, the program in health administration at the University of Colorado has played an important role in linking the graduate schools of business and public affairs and the undergraduate divisions of the social sciences (in particular, economics) with the teaching programs at the medical center. These liaisons were originally established because of the teaching program, but interdisciplinary research projects have since developed. Although undergraduate medical students undoubtedly benefit from courses that deal with the organization of health services, the pressures of their other coursework often limit their enthusiasm for this exposure--particularly when these courses are offered at the graduate level with its accompanying workload. As a result, only 34 medical students have elected to take these courses during the past five years. To enhance this element in the medical students' learning experience, separate and less demanding courses have been developed and offered as electives in the general preventive medicine curriculum. These electives include content in health economics, the organization of health services, health planning, and health policy formation. A course in the organization and management of a practice has also been developed as an elective for third-year residents. These courses have much more relevance at this stage of the student's development and have met with more enthusiasm than the courses planned for the undergraduate medical students. Our experience with the nursing and dental students has been quite different. The health administration courses have become favorite electives among the graduate nursing students, with about 40% of them taking at least one course each year. The dental school has gone a step further and has included health administration courses in the required curriculum. The expanding interest of physicians, nurses, and other health professionals in health administration and the increasing need for health administrators to be able to work closely with these other health professionals continue to reinforce our j u d g m e n t that health administration programs can and should be located in medical center settings. Medical schools considering a graduate program in health administration must recognize, however, that they are adding a teaching and a research dimension that differs considerably from the traditional medical school programs and one that is in many ways foreign to the medical school environment. To assure the success of a program and to achieve its maximum benefits, the health administration program must be fully discussed and accepted by the major departments within the school before being initiated.
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Equally important, the university's graduate school representative must understand and support the program so that he will be in a position to interpret the program to the basic sciences and to the other graduate programs. An uninformed or recalcitrant individual in that position will make it extremely difficult for a program to achieve the respect and stature necessary. Finally, support from the medical center administration is absolutely essential for the success of the program. Faculties may exert considerable short-run pressure on a program; but, in the long run, the dean's wishes will generally prevail. Lacking this support, health administration programs will find the medical school setting to be extremely problematic, and alternate settings should be considered.
SUMMARY
Formerly, the field of health administration was almost synonymous with hospital administration, and most graduate programs reflected that fact. However, given the growth in emphasis on the organizational and administrative aspects of health care during the past decade, a variety of important administrative positions have developed, and increased attention has been directed t o w a r d the role of the administrator as an important partner in organizing and distributing health services. In attempting to address these needs, the University of Colorado program in health administration was designed to prepare administrators for a variety of roles in the changing health system. The program was developed to provide students with a broad health system perspective and specific administrative skills. Because the program accepts only 18 to 20 new students a year, this five-year evaluation includes only 91 graduates; the survey suggests that the program has been at least partially successful in achieving the "health administration" goal, for the graduates have taken a wide variety of jobs within the health field. It also suggests, however, that graduates do not tend to change their general j o b categories and that someone pursuing hospital administration as the first j o b choice seldom takes a nonhospital position when moving to another job. Although the graduate program in health administration has progressed quite rapidly, the program's impact on the medical center's other teaching programs has been somewhat less than originally anticipated. In part, this has been due to the rather slow acceptance of this type of coursework by the curriculum committees, but an even more important factor relates to the medical, dental, and nursing students' ability to handle graduate coursework, given their extremely busy schedules. In order to accommodate the tolerance levels of thesestudents, less demanding courses had to be developed. Thus, while achieving some impact, the interdisciplinary benefits were lost. The relevance of some of the health service organization studies for medical students, when required during their undergraduate program, must also be questioned. The experience suggests that third-year residents are more appropriate recipients for this type of coursework because they will soon be developing a practice.
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Most academicians agree that at least some knowledge of health services organization is essential for medical, dental, nursing, and other students in the health sciences. The issue is when and how to provide this information. The Colorado experience indicates that the faculty and the coursework that have been developed around a graduate program in health administration can be an important resource in achieving this goal.
T H E F O R M A T I O N AND E V A L U A T I O N OF A GRADUATE PROGRAM IN H E A L T H A D M I N I S T R A T I O N W I T H I N A MEDICAL SCHOOL J o h n E. Kralewski, Ph.D., and J e f f r e y C. Bauer, Ph.D.
ABSTRACT: Several aspects of the program in health administration that was established in 1968 by the faculty of the University of Colorado School of Medicine are described. Based on the premise that knowledge about the organization and the delivery of health services had not kept pace with the advances made in the scientific foundations of medicine, the program was designed to provide training in management, accounting, economics, medical care organization, quantitative methods, and in the other skills required for health administration. The results of a survey to identify the extent to which the program's graduates have fulfilled the original objectives are presented, including a description of the graduates' backgrounds and current job situations. The lessons learned from five years' experience teaching health administration within a medical school are also reviewed. In 1968, the faculty o f the University o f Colorado School o f Medicine voted to establish a Division o f Health Administration within the D e p a r t m e n t o f Preventive Medicine. T h e division was to p r e p a r e administrators for work in the health field and to conduct studies dealing with the organization and delivery o f health services. In exploring ways to i m p l e m e n t the educational goal, the faculty concluded that traditional g r a d u a t e programs, which p r e p a r e d students for one specific institution, such as a hospital or a health d e p a r t m e n t , limited the graduates' career mobility and caused them to perceive their roles f r o m a r a t h e r narrow perspective. For these reasons, a master's d e g r e e p r o g r a m in health administration was established to p r e p a r e administrators who would seek and p e r f o r m administrative roles within the broad range o f existing and developing health care organizations. As a secondary goal, the p r o g r a m was also p l a n n e d to provide its nonclinical orientation to the students in clinical training p r o g r a m s at the medical center.
CURRICULUM
T h e c u r r i c u l u m was p l a n n e d so that all students would complete a core o f courses in basic m a n a g e m e n t principles, organizational behavior, managerial decision making, p r o g r a m planning and evaluation, quantitative methods, e c o Dr. Kralewski was Professor and Director of the Division of Health Administration, at the University of Colorado School of Medicine, 4200 E. 9th Avenue, Denver, Colorado 80262. He is now assistant to the Vice President, Health Sciences, and Professor and Director of the Center for Health Services Research at the University of Minnesota, Minneapolis. Dr. Bauer is an Assistant Professor in the University of Colorado, School of Dentistry. 150
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nomics, public health, and the sociopolitical aspects of health care. After completing these required studies, students select skill-area courses and field experiences that will broaden their exposure to the health care organizations within which they hope to begin their careers and that will provide them with the skills necessary to function effectively within these organizations. Such career environment areas include hospitals, planning councils, medical group practices, mental health centers, and neighborhood health programs. Skill-area coursework includes financial management and information systems, planning, evaluation, and policy analysis. Students normally spend two academic years in completing the program. A three-month summer field experience between the first and second years and field projects during the second year provide the students with a direct exposure to the specific career environment area elected. For example, a student who wishes to become a hospital planner would concentrate on planning studies, after completing the core courses, and would pursue various field experiences and class projects in the hospital setting. Students usually complete the core coursework during the first academic year; then, with their advisor, they develop a specialized course of study for the second year. Total coursework usually entails 60 to 70 quarter hours of credit.
GRADUATE
SURVEY
To identify the degree to which the program is meeting its original objectives, a questionnaire was mailed to all graduates in early 1975; 75 of the 91 graduates from the program's first five classes returned the questionnarie. Information on most of the remaining graduates was obtained by telephone or personal contact. Data on all students at the time of admission to the program were collected from their admissions records. The data from both the questionnaires and the admission forms were stored in a computer file, which can now be updated and analyzed at regular intervals.
ANALYSIS
In the following discussion, descriptive statistics are used to present the characteristics of the data file; the numerical results of the survey are given in absolute and relative terms. The absolute number of students reported in each category is followed in parentheses by the number as a percentage of the total number of complete responses; in other words, the percentage reports are adjusted for incomplete or inapplicable responses and different subsample sizes. Inferential statistics are not presented because of the small sizes of some subsamples that would have had to be analyzed. Although comparisons of groups for significant differences are not appropriate at the .present time, the information that is currently available indicates many interesting trends, which
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will be analyzed statistically when the number of graduates in the various subgroups has increased sufficiently.
RESULTS
The program's objective of preparing students for a wide variety of administrative jobs appears to have been at least partially achieved. Table 1 presents the responses to the questions that asked graduates to identify their major job responsibility and their institutional settings. The principal job descriptions are listed horizontally, and institutional settings are listed vertically. As shown in the columns, 47 graduates (51.6%) identified themselves as line administrators, 26 (28.8%) of whom were hospital administrators. In the next largest group, 24 graduates (26.7%) gave planning as their principal job responsibility. Of the planners, 9 worked for single hospitals or merged systems that include hospitals, 11 worked for planning agencies, including Comprehensive Health Planning (CHP), and 6 worked for consulting firms. The remaining graduates occupied a braod range of staff and teaching positions, or combined clinical medicine or dentistry with some administrative duties. The relatively high percentage of graduates performing planning roles in hospitals reinforces the program's initial premise that planning is a skill area within health administration rather than a separate discipline. Further, the 11 students who held positions in health planning agencies challenge the notion that graduates of health administration programs would not provide the planning manpower needed for these agencies. The data raise similar questions about the assumption that the prominence of hospitals in the field of health care would cause hospital administration to dominate the graduate programs in health administration and would attract most of the graduates. Fewer than one-third of the graduates have taken jobs as hospital administrators, and only 40% of the graduates are now working in hospital-connected positions. Clearly, the argument that hospital administration, comprehensive health planning, and other administrative roles cannot be linked under one educational rubric, that of health administration, does not hold true in this case. The graduates also worked in many institutional settings, as shown in Table 1. Single hospitals employed 32 graduates (35.2%), while 7 graduates (7.9%) worked in muhihospital health systems. Eight graduates (8.8%) worked for primary care clinics and 6 (6.6%) were employed by a Health Maintenance Organization (HMO). CHP (B) agencies employed 8 graduates (8.8%) and universities employed 10 (11%). The number of graduates in academic positions, 5 (5.5%), was an unexpected finding; all of these graduates were teaching in university medical centers, with 4 of the 5 in departments of community medicine. Regional Medical Programs (RMP), the Department of Health, Education, and Welfare (HEW) (including the Indian Health Service), and health departments and consulting firms employed the remaining 19 graduates.
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O f the 12 graduates with M.D. degrees, 9 listed administration as their primary job responsibility: 6 of the 9 combined administration with clinical responsibilities in group practice settings. The other three listed purely administrative job responsibilities, two in hospitals and one in an HMO; two M.D. graduates were teaching in combination with clinical practices, and one was involved entirely in clinical practice. Planning, either by itself or in combination with clinical practice, was not listed by any of the graduates with M.D. degrees. The number of physicians interested in the graduate program probably reflects the increasing role of the physician administrator. After reviewing the jobs now held by those graduates who were also physicians and the interest expressed by physicians now in the program, two major observations emerge: First, the role of medical directors in hospitals, group practices, and similar organizations is rapidly increasing in importance. This role deals with the quality of care, the relationships of medical staff to administration, the management of the medical component of patient care, and, frequently, the financial arrangements with the medical staff. Second, the physician's role as an administrator of community health programs was evident. In this context, the physician is the chief executive officer of what is often a relatively small program organized to provide health services to a specific population group. Neighborhood health programs, community mental health programs, migrant health programs, and a variety of the recently established rural health systems all fall under this rubric and are some of the programs now being administered by physician graduates of the health administration program. This dimension of the graduate program will likely receive increasing attention, as physicians' services become more highly organized in the future. Salaries
A question on their annual salary was answered by 71 graduates (78%). O f those who responded, 17 (25.4%) earned $15,999 or less per year at their current job. The others included 24 (35.8%) earning between $16,000 and $19,000, 13 (19.4%) in the $20,000 to $23,999 range; 17 (25.4%) were in the $24,000 and above category. As expected, salary levels varied considerably by age, work experience before entering the graduate program, and other credentials (such as the M.D. degree). Overall, four of the eight CHP (B) employees were in the $12,000$15,999 annual income category; one earned less, and the other three were in the $16,000-$19,999 category and none earned over $20,000. O f those employed in HEW or state health departments, five of nine earned above $24,000. In the hospital setting, 4 of 22 earned less than $17,000; 13 earned between $16,000 and $19,999, and 5 were earning above $20,000. (However, only 22 of the 32 graduates employed in hospitals answered the question about salary!) Our data indicate that line administrators are ranked approximately one group above planners in income. At the upper end, seven administrators earn $24,000; no planners are in this group. Although the small number of graduates
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in these categories limits the validity of comparisons, graduates taking hospital jobs generally do earn more than those in nonhospital jobs. Beginning salaries for the last two classes suggest, however, that these salary differentials are narr o w i n g - p e r h a p s indicating a change in supply or demand, or both, for administrators and planners. Student Backgrounds and Employment Analysis Several interesting observations arise from an analysis of the characteristics of entering students and comparisons of this information with postgraduate employment situations. For example, a fairly broad range of undergraduate academic backgrounds was reflected in the students who were admitted to the program: 23 (26.4%) students had undergraduate specialties in the natural sciences. Business and social science majors were ahnost as numerous, with 21 (24.1%) and 19 (21.8%) students, respectively. Other majors included seven (8%) in the humanities, five (5.7%) in pharmacy, three (3.4%) in journalism, two (2.3%) in engineering, one (1.1%) in health administration, and six (6.9%) in other fields. Of the graduates, 22 (24.1%) had also received graduate degrees prior to their admission to the M.S. program in health administration. These advanced degrees included medicine, dentistry, business, and law. In response to questions about additional education since graduation from the health administration program, 31 (35.6%) of the respondents said that they intended to pursue further advanced degree work. However, only one student had actually done so at the time of the survey. The cross-tabulation of undergraduate majors and salary ranges showed that majors in the humanities and the natural sciences had the highest relative numbers of graduates earning $20,000 and above. The figures are 4 (66.7%) and 10 (58.8%), respectively. Only 7 of 18 business majors (38.9%) and 2 of 12 social science majors (16.7%) were in the highest income categories. A cross-tabulation of the students' undergraduate majors and the institutional setting of their current jobs revealed some interesting trends. For example, 16 business majors (76.3%) were working in hospital settings, while natural science majors were distributed relatively equally across all institutional settings. Majors in pharmacy,journalism, and the humanities were similarly scattered. All four of the graduates now working for consulting firms and five of the eight CHP (B) agency employees were social science majors. A comparison between the student's state of residency at entrance and the state where currently employed indicated that 27 of the 44 graduates (62.8%) who were classified as Colorado residents at entrance have remained in the state after graduation. Additionally, 19 of 47 out-of-state residents (40.4%) have also elected to stay in Colorado. Therefore, slightly over half of all students graduating during the past five years reside and work in Colorado. Only 7 of the 47 graduates (15%) from other states had returned to their home states for their current jobs. Although the determination of residency at entrance was based on some subjective criteria, the state where graduate training was completed
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(Colorado) seems to have been more important than their original state of residency as a determinant of geographical location after graduation. This finding may reflect the fact that the field experience that takes place between the first and second years of the graduate program and the field projects during the second academic year cause students to make most of their personal contacts in Colorado. The presumed attractiveness of Colorado as a place to live must also be taken into consideration. In either event, the program clearly has had a substantial impact on the state of Colorado, in terms of providing educational opportunities for students and supplying manpower in the health administration field. Nearly two-thirds of the health planners in the state are graduates of the Colorado program; and two of the three operating HMOs were started by the program's graduates. The major health care programs for underserved rural areas are run by graduates of the program, and nearly 25% of the hospitals in the state, including the university hospital, have graduates of the program on their staff.
PROGRAM SETTING
This discussion would be incomplete without some brief comments about the role of a medical school as the setting for a graduate program in health administration. The University of Colorado program was purposely developed within the medical school to integrate health administrators and physicians during their training and to add the dimension of health administration to the teaching, research, and community service programs of the school. The medical center leaders believed that the school should address organizational and administrative needs and concerns in addition to the traditional clinical and basic science areas. They also believed that physicians would be better equipped to deal with the changing health care system if exposed to health services and health administration coursework during their medical school training. The development of a graduate program in health administration in a medical school will not assure rapid achievement of these goals. Although some academic administrators and students may perceive the need for addiing organizational and administrative courses to the curriculum, many faculty members from the clinical and basic sciences remain unconvinced, and some may feel threatened by this intrusion. The difficulties of achieving respect for health administration as an academic discipline, and for nonmedical faculty as creditable academicians, present serious barriers that sometimes limit program effectiveness in this setting. Many medical schools are exploring the development of graduate prograins in health administration and community health. According to a recent survey conducted by Conrad and Berg, 17 medical schools already report the existence of formal academic programs in these areas (mimeographed report,
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Emory School of Medicine, Atlanta, Georgia). Medical schools or health science centers provide attractive settings for graduate education in health administration; their commitment to excellence in education is widely acknowledged. Their rigorous academic standards, research orientations, and relatively high facultyto-student ratios are well recognized. Health administration programs in these settings provide a bridge between the clinical disciplines and the other academic disciplines that are interested in the organizational and administrative aspects of health care. In this regard, the program in health administration at the University of Colorado has played an important role in linking the graduate schools of business and public affairs and the undergraduate divisions of the social sciences (in particular, economics) with the teaching programs at the medical center. These liaisons were originally established because of the teaching program, but interdisciplinary research projects have since developed. Although undergraduate medical students undoubtedly benefit from courses that deal with the organization of health services, the pressures of their other coursework often limit their enthusiasm for this exposure--particularly when these courses are offered at the graduate level with its accompanying workload. As a result, only 34 medical students have elected to take these courses during the past five years. To enhance this element in the medical students' learning experience, separate and less demanding courses have been developed and offered as electives in the general preventive medicine curriculum. These electives include content in health economics, the organization of health services, health planning, and health policy formation. A course in the organization and management of a practice has also been developed as an elective for third-year residents. These courses have much more relevance at this stage of the student's development and have met with more enthusiasm than the courses planned for the undergraduate medical students. Our experience with the nursing and dental students has been quite different. The health administration courses have become favorite electives among the graduate nursing students, with about 40% of them taking at least one course each year. The dental school has gone a step further and has included health administration courses in the required curriculum. The expanding interest of physicians, nurses, and other health professionals in health administration and the increasing need for health administrators to be able to work closely with these other health professionals continue to reinforce our j u d g m e n t that health administration programs can and should be located in medical center settings. Medical schools considering a graduate program in health administration must recognize, however, that they are adding a teaching and a research dimension that differs considerably from the traditional medical school programs and one that is in many ways foreign to the medical school environment. To assure the success of a program and to achieve its maximum benefits, the health administration program must be fully discussed and accepted by the major departments within the school before being initiated.
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Equally important, the university's graduate school representative must understand and support the program so that he will be in a position to interpret the program to the basic sciences and to the other graduate programs. An uninformed or recalcitrant individual in that position will make it extremely difficult for a program to achieve the respect and stature necessary. Finally, support from the medical center administration is absolutely essential for the success of the program. Faculties may exert considerable short-run pressure on a program; but, in the long run, the dean's wishes will generally prevail. Lacking this support, health administration programs will find the medical school setting to be extremely problematic, and alternate settings should be considered.
SUMMARY
Formerly, the field of health administration was almost synonymous with hospital administration, and most graduate programs reflected that fact. However, given the growth in emphasis on the organizational and administrative aspects of health care during the past decade, a variety of important administrative positions have developed, and increased attention has been directed t o w a r d the role of the administrator as an important partner in organizing and distributing health services. In attempting to address these needs, the University of Colorado program in health administration was designed to prepare administrators for a variety of roles in the changing health system. The program was developed to provide students with a broad health system perspective and specific administrative skills. Because the program accepts only 18 to 20 new students a year, this five-year evaluation includes only 91 graduates; the survey suggests that the program has been at least partially successful in achieving the "health administration" goal, for the graduates have taken a wide variety of jobs within the health field. It also suggests, however, that graduates do not tend to change their general j o b categories and that someone pursuing hospital administration as the first j o b choice seldom takes a nonhospital position when moving to another job. Although the graduate program in health administration has progressed quite rapidly, the program's impact on the medical center's other teaching programs has been somewhat less than originally anticipated. In part, this has been due to the rather slow acceptance of this type of coursework by the curriculum committees, but an even more important factor relates to the medical, dental, and nursing students' ability to handle graduate coursework, given their extremely busy schedules. In order to accommodate the tolerance levels of thesestudents, less demanding courses had to be developed. Thus, while achieving some impact, the interdisciplinary benefits were lost. The relevance of some of the health service organization studies for medical students, when required during their undergraduate program, must also be questioned. The experience suggests that third-year residents are more appropriate recipients for this type of coursework because they will soon be developing a practice.
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Most academicians agree that at least some knowledge of health services organization is essential for medical, dental, nursing, and other students in the health sciences. The issue is when and how to provide this information. The Colorado experience indicates that the faculty and the coursework that have been developed around a graduate program in health administration can be an important resource in achieving this goal.
