General Medical and Surgical Hospitals

SIC 8062

Companies in this industry

Industry report:

This industry consists of establishments primarily providing general medical and surgical services and other hospital services in a hospital setting. This grouping excludes specialty hospitals classified in SIC 8069: Specialty Hospital, Except Psychiatric and psychiatric hospitals covered in SIC 8063: Psychiatric Hospitals.

NAICS Code(s)

Industry Snapshot

The location and use of U.S. hospitals changed significantly during the late twentieth and early twenty-first centuries. According to the American Hospital Association (AHA), the 5,754 hospitals in the United States in 2010 admitted more than 36.9 million patients. The overall number of community hospitals had declined from 5,611 in 1987 to 4,985 in 2010. Although community hospitals in urban settings posted a slight decline during this time, dropping to 2,998, the number of rural community hospitals fell more significantly, reaching 1,987. In addition, from 2007 to 2010, the number of hospital beds declined from 956,529 to 941,995. In 2011 U.S. hospitals generated $786 billion in revenues and employed approximately 5.4 million people.

At the end of the first decade of the 2000s and in the early 2010s, hospitals experienced increasingly fiscal, government, and consumer pressure to provide higher quality service at lower costs while increasing access and preserving patient choice. One response was to dramatically reduce the length of hospital stays. The average length of stay in the late 1980s was slightly more than seven days. By the end of the first decade of the 2000s, the average length of stay had fallen to five and one-half days. Inpatient days per 1,000 persons declined between 1987 and 2007 from 937 days to 645 days, respectively. While hospitals focused on outpatient care, other facilities began to take over many outpatient procedures and surgeries. In 2001 hospitals performed 93 percent of all outpatient surgeries, and freestanding facilities and doctors' offices performed 4 percent and 3 percent, respectively. However, hospitals' dominant role declined steadily over the next 25 years, and by the middle of the first decade of the 2000s, hospitals conducted less than 45 percent of outpatient procedures while freestanding clinics and doctors' offices were performing 38 percent and 17 percent, respectively. In 2008 there were 5,875 outpatient surgery centers in the United States, up from 3,605 in 2003.

At the end of the first decade of the 2000s, hospitals in the United States were being negatively affected by the global economic recession. As a result, fewer people were seeking treatment, and those who were admitted were much more likely to be uninsured or recipients of Medicare and Medicaid, which paid lower rates of reimbursement. At the same time, many hospitals had declining revenues from investments due to poor returns on Wall Street. Consequently, hospitals cut costs, delayed capital improvements, and waited for better times. A slow recovery was beginning in the early 2010s.

Organization and Structure

General and surgical hospitals are generally categorized as nonprofit, profit-making, and both state and local government establishments. According to the AHA, there were 2,904 nongovernment, nonprofit hospitals; 1,013 for-profit hospitals; 1,068 state and local government hospitals; and 213 federal government hospitals in the United States in 2010. Other types of hospitals classified by the AHA included nonfederal psychiatric (435), nonfederal long-term care (111), and hospital units in institutions, such as prisons (10). During the 1990s, community hospitals increasingly became part of multihospital systems, where one owner or an ownership group owned more than one hospital. Although mergers and acquisitions declined during the early years of the first decade of the 2000s, beginning in 2004 the number of deals began to pick up once again. Between 2004 and 2007, there were 225 mergers and acquisitions involving nearly 400 hospitals.

Hospitals receive their revenues from different sources for the services they provide to patients. At the end of the first decade of the 2000s and in the early 2010s, the largest source of income to community hospitals came from Medicare and Medicaid programs. According to data released in January 2009 by the Centers for Medicare and Medicaid Services, of the $2.24 trillion spent on health care in 2007, government funds provided 46.2 percent, or $1.04 billion. Specifically, Medicaid accounted for 19.2 percent of funding; Medicare, 14.7 percent; and other government funding, 12.3 percent. Private insurance paid 34.6 percent, or over $775 billion; out-of-pocket expenses accounted for 12 percent, or $268.9 billion; and the remaining 7.2 percent came from other sources.

Hospital expenses are strongly affected by legislation, costs of medical technology, and trends in medical practice. As these expenses rose throughout the first decade of the 2000s, on-site administrative, food service, maintenance, and laundry support often were streamlined or contracted out in response. To counteract rising costs, many hospitals also attempted to expand their revenues by increasing their role in community health maintenance efforts beyond traditional emergency, obstetrics, and inpatient care to include disease prevention and patient education programs, such as weight reduction, drug rehabilitation, prenatal care, and pediatric wellness.

Internally, hospitals are structured around an administrative staff that oversees nursing and administrative functions and separately operates medical staff and ancillary services, such as a pharmacy and the services of various therapists.

Background and Development

Early hospitals were established by governments and religious groups for care of special segments of the population, such as the poor, the military, and slaves. In Europe, doctors and other medical staff were not paid for their services in hospitals because such services were regarded as Christian charitable work. Records show that during the Middle Ages, medical staffs of charity workers were divided into two groups that rotated their work each month.

Starting in the thirteenth century, hospitals greatly increased in number throughout Europe. With this change, hospitals gradually became more secular and began paying their medical staffs. At this time, and up until the eighteenth century, private patients in a hospital ward were virtually nonexistent. Hospitals were regarded as places for the poor, while wealthy patients were usually treated in their homes by hired physicians.

By the late eighteenth and early nineteenth century, another form of hospital emerged. "Voluntary" institutions were developed with the idea of providing charitable treatment for all segments of the population. These s grew into the "nonprofit" U.S. hospitals of the twentieth century.

Early hospitals in the United States followed the pattern of their European predecessors, with most hospitals growing of houses and treatment centers for special groups of the population. Many of these early U.S. hospitals were often quickly built in order to confine the spread of contagious diseases. The first hospitals in the United States were Bellevue Hospital, founded in New York in 1658, and Philadelphia Hospital, founded in 1713. Both institutions were originally intended for the insane, the aged, and the poor.

In 1752 the Pennsylvania Hospital was founded as a voluntary hospital to serve both the poor in large public wards and other patients in private rooms. The latter were affluent patients who paid both the physician and the hospital for their services. However, hospitals in Europe and the United States continued to be viewed as places for the poor until the nineteenth century, when medical technology made large advances. Hospitals began to use anesthesia, which was considered by experts to represent a turning point for hospitals; new medicines; and sterile environments, making hospitals safer places for treatment.

The nineteenth century brought about other significant developments for hospitals. Hospitals became the centers of medical education and research. In addition to doctors, other medical staff, most notably nurses, became professionals in their own right, developing their own professional standards and certifications. It was also during 1800s that the health insurance industry started. Patient insurance began in Germany in 1883 and was operated and paid for by the German government, while in the United States the responsibility was assumed by private insurance companies.

The twentieth century was a time of remarkable changes in this industry. Technological advances in radiology meant earlier diagnosis of many fatal ailments, particularly cancers, and treatment of those conditions. Many fields in medicine have developed, such as obstetrics, pediatrics, and transplant surgery, along with departments providing these services in hospitals.

In response to the post-war baby boom, the 1950s was a time of large growth in the number of hospitals throughout the country. Medical schools and teaching hospitals grew to meet the demands of the new generation. From 1970 until 1990, the role of hospitals in U.S. society and their function within the larger health care industry changed significantly. The number of U.S. hospitals began to decline, from 7,123 with 1.6 million beds to 6,400 with 992,000 beds. Additionally, the rate of occupancy in hospitals dropped from 80 percent in 1970 to 66.1 percent in 1994. In 1995 the Journal of the American Medical Association projected hospital admissions would decline an additional 26 percent and average length of stay would drop another 11 percent by the end of the century.

The ongoing reduction in the number of hospitals and the drop in occupancy rates reflected a general trend away from traditional inpatient care to procedures that could be done just as effectively but even more economically on an outpatient basis. Outpatient visits at all U.S. hospitals accordingly rose from 181 million in 1970 to 454 million in 1994. Much of this movement resulted from government legislation and health insurance plans offering more coverage for less costly treatments that did not require overnight stays. Additional growth was spurred by technical advances in outpatient surgical procedures, which caused the number of all surgeries performed outside a traditional hospital setting to rise from 24 percent in 1983 to 55 percent in 1993.

Since the 1970s, the ownership of hospitals shifted from individual establishments to chains of hospitals. This enabled hospitals to share technology and management resources across their numerous facilities and cut costs due to economies of scale. Moreover, it allowed hospital owners to begin specializing their ownership services by dividing hospitals into the three main industry groups: general medical and surgical, psychiatric, and other specialties. The consolidation was not without problems, however, especially as it changed some nonprofit institutions into for-profit enterprises, which were not always highly regarded.

Services Offered by Hospitals.
General medical and surgical hospitals provide a variety of hospital-based health services. In 1996 more than 92 percent of hospitals in the United States had emergency departments. Nearly 74 percent of hospitals offered general inpatient care for those with AIDS, which was an increase from 61 percent in 1992, while 6.7 percent offered specialized outpatient AIDS programs. Therapy services also comprised a large portion of services provided by general medical and surgical hospitals, with 91.2 percent of these hospitals offering respiratory therapy services, 85.5 percent providing physical therapy programs, and 55.5 percent assisting with occupational therapy. Addressing the needs of the aging population, U.S. hospitals increased their geriatric services during the 1980s and 1990s. By the mid-1980s, nearly two-thirds of all hospitals offered one or more geriatric services, including geriatric response, which monitored elderly patients in their homes and linked them with hospitals in an emergency; respite care facilities; and geriatric acute care units. A small number of hospitals added Alzheimer's diagnostic and assessment services and adult day care facilities. However, the fastest growing field within geriatric care was psychiatric services. In 1992, 27 percent of general hospitals offered geriatric mental health programs. The majority of geriatric mental health programs were only available at non-community hospitals, such as large university hospitals and hospitals run by the Department of Veteran Affairs.

According to the American Hospital Association, 87 percent of general medical and surgical hospitals in the United States had an official outpatient department in 1993, while almost 94 percent offered at least some outpatient surgery services. That year, outpatient surgical procedures accounted for 55 percent of all surgeries performed in community hospitals. About 85 percent of all hospitals had blood banks, more than 66 percent had birthing rooms, and nearly 85 percent had ultrasound. Approximately 21 percent of hospitals offered alcohol/chemical dependency care, and 23 percent had psychiatric services. In the 1990s, many hospitals also opened outpatient clinics that specialized in the treatment of pain. These clinics varied in size and specific types of treatments offered. With the growth in managed care and patients seeking alternatives to costly inpatient stays, these clinics were expected to increase in the late 1990s. Another significant growth area for outpatient services was in home health care, and in 1993, 41.5 percent of all community hospitals offered home health care services.

In the 1990s, community hospitals also provided a growing array of health promotion services. In 1993 the American Hospital Association reported that more than 88 percent had patient education programs. Approximately 60 percent of all hospitals offered worksite health promotion programs.

Medicare and Medicaid.
Medicare and Medicaid are federally funded health insurance programs that provide assistance to patients over 65 years of age and patients with low incomes or end-stage kidney disease or disabilities. In 1993 Medicare paid for 51 percent of all inpatient hospital visits and 8 percent of outpatient hospital costs, while Medicaid paid for 27 percent of inpatient stays and 6 percent of outpatient charges. The Hospital Insurance (HI) program within Medicare pays for care given at hospitals, home health agencies, hospices, and skilled nursing facilities. In 1997 HI payments totaled $137.8 billion for 38 million enrollees.

The introduction of Medicare and Medicaid programs in the early 1970s significantly impacted this industry. In 1970 Medicare and Medicaid accounted for slightly more than 6 million patient admissions to general medical and surgical hospitals and paid for $5 billion of their hospital charges. By 1993 Medicare alone paid $76.3 billion in inpatient hospital charges. Between 1980 and 1990, the number of Medicaid recipients receiving inpatient treatment rose 913,000 annually, while the number of Medicaid patients receiving outpatient care rose 2.6 million annually. By 1995 Medicare was the largest single insurer in the United States, covering about 14 percent of the entire population. As the population continued aging and additional advances were made in medicine and technology, Medicare funds for people over 65 years of age became the largest portion of all hospitals' government-funded health coverage.

Medicare and Medicaid programs also affected hospital management, requiring greater training in nonmedical matters in order to deal with paperwork regulations and various service requirements. However, cutbacks and changes in the payment systems in Medicare and Medicaid during the 1980s and early 1990s had a large impact on the industry's bottom line. In 1991, $43 billion was cut from the Medicare budget, and in 1996 President Clinton vetoed a Republican balanced budget plan that would have mandated Medicare cuts of $270 billion and Medicaid cuts of $163 billion by 2000. The president's alternative called for $124 billion in Medicare reductions, so although no compromise was immediately reached, the hospital industry was ready for even more changes.

As part of the overall realignment, the Health Care Financing Administration (HCFA), which managed Medicare, proposed fixed-rate pricing on many medical services. The benefits and effectiveness of this new pricing system continued to be debated by many through the early 2010s.

Mergers.
Mergers and joint ventures played important roles in this industry as a way of sharing the costs of needed technology and trimming redundant costs. Moreover, as the occupancy rate increased in hospitals across the country, joint ventures opened means of sharing liabilities to reduce the impact of financial downturns on individual hospitals.

In the late 1980s, the federal government imposed antitrust rulings in two highly publicized cases prohibiting the merger of certain hospitals. Following this action, a few mergers per year were investigated by federal agencies. As a result, the American Hospital Association ran a campaign to have antitrust laws relaxed, believing such laws hindered mergers and joint ventures between hospitals. As of the early years of the first decade of the 2000s, the government had not reversed any of its rulings concerning antitrust laws over hospital mergers. However, this issue remained important to this industry as it moved into the twenty-first century.

Malpractice.
By the 1990s, the American Medical Association estimated that $15 billion of the nation's health costs went toward "defensive medicine," additional tests and diagnostic procedures carried out to protect doctors from malpractice claims. For this reason, the increase in malpractice cases, particularly during the mid-1980s, increased the use of hospital laboratory facilities. However, malpractice cases were more noted for negatively affecting this industry. Because hospitals have more insurance and larger revenues than individual doctors, they are often the targets of such suits. In the early 1990s, hospitals responded to malpractice cases by increasing medical staff decisions and reviews of doctors' procedures. Hospitals also started protecting their assets by placing them in separate corporations or endowments.

Hospitals and Pollution.
Establishments in this industry have long dealt with the problem of waste disposal. Hospitals generate large amounts of general waste, such as paper and food. They also have to dispose of chemical and pathogen waste.

Until the late 1980s, hospitals in the United States disposed of medical wastes by using on-site incinerators, which were effective in burning wastes but polluted the air. In 1988 nine states passed medical-waste disposal legislation, and in 1989 an additional 22 states passed these types of laws. By 1990 new government standards, mostly at the state level, affected an estimated 6,000 hospital incinerators. Complying with the new standards imposed costs of between $500,000 and $1 million on each hospital.

To avoid the direct financial burden of upgrading incinerators, small hospitals, especially those in rural areas, banded together to share regional incinerators which met the new air pollution standards. However, this approach introduced new costs related to hauling waste to the incinerator.

As a result of overexpansion of facilities in the 1970s and the economic recession at the beginning of the 1990s, hospitals struggled without easy access to capital and charitable funding. Between 1985 and 1995, Modern Health Care reported that approximately 600 acute care hospitals closed, eliminating about 180,000 beds. Nevertheless, some believed that with the ongoing fiscal belt-tightening, as many as 447,000 unnecessary beds remained, which was enough to fill almost 2,500 hospitals.

In order to deal with the various financial problems they faced, some companies in this industry increased their psychiatric units and rehabilitation clinics, both of which were high-profit facilities. Nearly all hospitals expanded their outpatient services, which generally brought in lower profits than inpatient units but yielded continuous revenues. Many began to automate routine administrative tasks.

This industry entered the 1990s suffering from a public image problem that affected the nonprofit status of most U.S. hospitals. This situation was a result of public criticisms of hospital pricing practices, the growing number of malpractice cases, and the way hospitals assumed a more business-like approach to managing their establishments. The decision by 447 formerly single-unit community hospitals to merge with larger corporations in 1995, along with the conversion that year of 58 nonprofit hospitals to for-profit status, did not help the industry's overall public image.

The business-like approach that generally marked the entire industry was characterized by "quality management." Instead of leaving the quality of care in the hands of individual practitioners, hospitals instituted measures to prevent faulty processes from occurring. Quality management was originally adopted by hospitals to improve food service and lower the length of patient stays. However, in the 1990s this approach was also used for clinical decisions and processes. Although hospital revenues had increased a total of 404 percent, from $102 billion in 1980 to $412 billion in 2000, costs incurred by hospitals also increased, rising 429 percent from nearly $92 billion in 1980 to more than $395 billion in 2000.

The shift toward more outpatient care also affected hospital management. Although hospitals accounted for outpatient care separately from inpatient treatment, management of the two types of services was traditionally under one supervisor. However, in the 1990s, hospitals started moving toward specialized management to unite the various types of outpatient services while keeping them separate from inpatient care.

At the end of 2002, hospital industry advocates were calling for increased provider payment relief for 2003, noting that more than half of the members of the American Hospital Association (AHA) reported losing money on Medicare in 2000. In addition, around 60 percent lost money in the Medicaid program, and about one of every three hospitals reported a year-end loss. They also noted that profit margins in 2001 were at the lowest they had been since 1993. The annual profit margin for 2001 was 4.2 percent, down from 4.6 percent the previous year. Total revenue for U.S. hospitals grew 7 percent, reaching $400.6 billion in 2001, up from $373.5 billion in 2000. However, costs also increased 7 percent, from $356.5 billion in 2000 to $383.7 billion in 2001. The AHA cited higher costs for labor, new technology, and medical liability insurance, as well as bioterrorism preparedness, as factors in the increase in costs.

Hospitals anticipated a growing customer base as the average age of Americans continued to rise. However, ongoing cuts in Medicare and Medicaid, rising insurance premiums, and increased costs of medical technology, as well as a new focus on emergency preparedness in the wake of the terrorist attacks of September 11, 2001, against the United States, could leave hospitals with more patients that would result in financial losses.

In 2005 the industry reported 12,734 general and surgical hospitals (93.6 percent of the industry total) staffed by 3.52 million medical professionals who generated $513.8 billion in annual revenues. On average, an individual general and surgical hospital employed 359 people with revenues of $66.8 million. Additional sectors within the general medical and surgical hospitals industry included 186 hospitals affiliated with the American Medical Association (AMA) residency program, with a support staff of 115,921 people and revenues of more than $15 billion, while AMA-approved residency hospitals employed 86,930 people and had revenues of more than $11 billion. In addition, hospitals with medical school-affiliated residencies employed 94,041 people with more than $10 billion in annual revenues, and hospitals with medical school affiliations had 87,146 employees and reported annual revenues of more than $8.5 billion.

Research conducted by Johns Hopkins Bloomberg School of Public Health found the United States spent more on health care than other countries by a significant margin. However, research focused on malpractice litigation and supply constraints found no logical explanation for the cost discrepancy compared to the rest of the world.

Other issues facing the industry during the middle of the first decade of the 2000s stemmed from reports that concluded an estimated 98,000 patients died annually because of medical mistakes. As a result, the Joint Commission on Accreditation of Health care Organizations put in place procedures "for enhancing the safety, quality, and excellence of patient surgical care." This caused states to pass legislation to lower the alarming number of mishaps, and to require hospitals and surgical facilities to implement procedures for reducing errors.

Keeping a strong fiscal bottom line had long been a challenge in the hospital industry, but it proved to be increasingly difficult during the end of the first decade of the 2000s in the face of a global economic recession. Many people put off medical care and procedures to conserve financially. As a result, hospital admittances were down overall, but the number of emergency room visits and the number of nonpaying and uninsured patients and patients relying on Medicare and Medicaid increased. Treating Medicare and Medicaid patients was problematic for hospitals because reimbursements were low for these government-funded programs. According to an AHA survey, Medicare and Medicaid paid less than $0.90 for every $1.00 of cost to the hospital, resulting in hospitals losing money when they treated Medicare and Medicaid patients, amounting to more than $30 billion annually. In addition, research by the Kaiser Foundation found that hospitals incurred $35 billion in losses for unpaid fees in 2008. These costs were pushed onto the private payer, who paid $1.32 for every $1.00 of hospital cost in 2007. Nonetheless, one-third of U.S. hospitals operated at a loss.

With further cuts to Medicare and Medicaid proposed as part of the health care reform debate and the number of the uninsured on the rise, hospitals attempted to trim costs at the end of the first decade of the 2000s. The AHA survey revealed that 9 of 10 hospitals reported in 2009 that they were cutting back. Almost one-half had reduced staff, and 80 percent had cut administrative costs. Twenty percent reported that they had reduced services to the community such as behavioral health, patient education, and postacute care. Eighty percent reported deciding to slow or postpone capital improvements and Internet technology expenditures, including surgical, diagnostic, and clinical equipment upgrades. Nonetheless, more than 45 percent were operating in the red during at least part of 2009.

Because Medicare and Medicaid were major sources of funding for hospitals, the outcome of President Obama's proposed health care reform was of significant interest to the industry in 2009. Due to the recession, Medicaid rosters in many states were climbing, rising 5.5 percent in 2008 and 6.6 percent in 2009, and states were either freezing or cutting Medicaid payments to meet the new demands. In addition, with the aging baby boom generation, Medicare enrollment was expected to explode through the 2010s, from 44.9 million in 2008 to 56.9 million in 2017.

Current Conditions

Multiple challenges were apparent in the hospital industry in the United States at the beginning of the 2010s, including high labor costs caused by personnel shortages, increasing consumer demands, and an increasing number of people without health insurance. In addition, according to a 2012 report by IBISWorld, "reimbursement from Medicaid and Medicare will continue to be strained as the government seeks to finance health care reform and states deal with budget deficits, restraining profitability." However, there were also positive factors that were expected to contribute to the industry's growth, including an aging American population and an improvement in the economy. The IBISWorld report predicted an annual growth of approximately 3 to 4 percent between 2012 and 2017.

Industry Leaders

Hospital Corporation of America (known as HCA) was the largest for-profit hospital system in the United States in the early 2010s. HCA operated 163 hospitals, including acute care, psychiatric, and rehabilitation, in addition to 109 ambulatory surgery centers and other outpatient and treatment centers, such as diagnostic imaging, cancer treatment, and rehabilitation services. Headquartered in Nashville, Tennessee, HCA had facilities in 20 states and England, and the company employed 199,000 people. Privately-owned HCA reported revenues of $28.4 billion in 2008. Revenues for the first quarter of 2012 reached $8.3 billion.

Tenet Healthcare Corporation was the second-largest hospital chain in the United States. Following a series of scandals over billing practices, it trimmed its holdings from 116 hospitals in 16 states to 50 acute care hospitals in 11 states (primarily California, Georgia, and Texas). Tenet's hospitals ranged from rural general hospitals to large, university-linked teaching and research hospitals. It also operated 99 outpatient centers. After posting net losses of $805 million and $89 million in 2006 and 2007, respectively, the publicly held company, which had operated a vast regional health care delivery system, was back in the black in 2008. Revenues for 2011 were $8.8 billion, and the firm employed 57,000 workers.

Ascension Health, headquartered in St. Louis, Missouri, was the number one Catholic hospital system, as well as the largest private, not-for-profit health care system in the United States. Ascension was formed in 1999 by the merger of Daughters of Charity National Health System and the Sisters of St. Joseph Health System. During the early 2010s, it had 1,400 locations, including general acute care hospitals, additional rehabilitation, and psychiatric hospitals, throughout 21 states and the District of Columbia. The company recorded $15.5 billion in revenues in 2011, with more than 107,000 employees.

Workforce

According to the U.S. Department of Labor Bureau of Labor Statistics, the hospital industry accounted for 5.6 million jobs in 2010. Mean annual salaries ranged from $201,000 (surgeons) to about $22,000 (cafeteria help). Health care practitioners and technical occupations, including doctors, nurses, and therapists, accounted for over half of all jobs. Nurses comprised almost one-third of the hospital industry workforce, with an annual mean salary of $64,690. Office and administrative support accounted for slightly more than 15 percent of the workforce, and health support occupations, including health aides, orderlies, and attendants, represented nearly 13 percent of jobs.

The overall job outlook for people working in hospitals was steady at the end of the first decade of the 2000s and in the early 2010s, despite a slowly recovering economy and high rate of unemployment. For example, although all nonfarm industry jobs reported a loss of -0.5 percent in both December 2008 and January 2009, the hospital jobs rate increased 0.2 percent and 0.1 percent, respectively.

Job prospects for registered nurses were expected to be high through 2017 as the industry continued to deal with a shortage of nurses. About 59 percent of the United States's 2.5 million nurses worked in hospitals, and the U.S. Bureau of Labor Statistics projected that 578,000 nursing jobs would be created between 2006 and 2016. However, not all sectors of the health care industry had equal demand for nurses. Projected growth was highest in physicians' offices and home health firms (39 percent each). Nonetheless, projected growth in 2011 for nursing jobs in hospitals was still well about average at 26 percent.

© COPYRIGHT 2018 The Gale Group, Inc. This material is published under license from the publisher through the Gale Group, Farmington Hills, Michigan. All inquiries regarding rights should be directed to the Gale Group. For permission to reuse this article, contact the Copyright Clearance Center.

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