One of the big worries with health care reform and access expansion was finding the providers to treat patients. The evidence has consistently shown that people with insurance are more likely to use services than people without insurance, so there would always be a net incremental increase in demand for services. However the US primary care doctor pool slowly grows and it can not quickly respond, so who would treat all of the new patients and cover all of the new appointments?
That is an excellent question, and one of the dominant sources of new coverage and care is through the loosening of scope of practice requirements for master level clinicians such as Certified Nurse Practicitioners, nurse midwives, physician assistants and nurse anesthesiologists. Below are a couple of recent stories about how these providers are able to give a reasonable baseline of care:
There are just a handful of psychiatrists in all of western Nebraska, a vast expanse of farmland and cattle ranches. So when Murlene Osburn, a cattle rancher turned psychiatric nurse, finished her graduate degree, she thought starting a practice in this tiny village of tumbleweeds and farm equipment dealerships would be easy.
It wasn’t. A state law required nurses like her to get a doctor to sign off before they performed the tasks for which they were nationally certified. But the only willing psychiatrist she could find was seven hours away by car and wanted to charge her $500 a month. Discouraged, she set the idea for a practice aside and returned to work on her ranch….
Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.
A new bill in Congress is looking to expand the scope of practice for the Veteran’s Administration’s master level clinicians:
Senate legislation is looking to empower nurse practitioners across the Veterans Affairs Department to practice independently of physicians, regardless of laws in individual states. The goal is to mitigate physician shortages and reduce patient wait times that have been plaguing the VA.
The provision would allow nurse practitioners—including midwives and mental healthcare clinical nurse specialists—to prescribe some drugs and treat patients without a supervising physician.
The goal is to increase the provider supply to reduce wait times and to meet demand without long waits. CRNPs, PAs and other master level clinicians do have less initial training than an MD/DO, but most of the time, they are dealing with a fairly restricted universe of problems where the initial training plus experience and continual education is more than sufficient to appropriately treat people. This is especially true of primary care where most of the time galloping animals that are sixteen hands tall truly are horses instead of zebras. As long as master level clinicians have a referal system in place to send their wierd cases, this is a net win as more people get covered at a lower cost per unit of service.
John M. Burt
It will be interesting to find out how this is a horrible thing and proof (“if more were needed”) that the ACA is secretly President Obama’s master plan to bring the country down.
Beth in VA
Sometimes nurses can be so much more helpful, but I have noticed more and more no doctor is available when we need an appointment, and the nurse practictionor does not get the diagnosis right. I feel like this will just make another step between me and my doctor. The amount of training between MDs and RNs, and the depth of training, is much different.
currants
Yes, generally, I agree.
From a non-healthcare point of view, however, it will be interesting to watch the impact of this on those professions and their income vis a vis gender. That is, do those professions become more male or female dominated, and which way do their earnings trend?
Richard Mayhew
@currants: Master level clinicians are mostly female while new MD/DOs are 1:2 female to male split
Richard Mayhew
@Richard Mayhew: New MD/DO grads are about 50/50 female, but oldest cohorts are overwhelmingly male, and young female docs have lower work force participation rate (child rearing usually)
http://www.theatlantic.com/sexes/archive/2012/12/more-women-are-doctors-and-lawyers-than-ever-but-progress-is-stalling/266115/
Luthe
I’m all for this. My current psychiatric provider is an APRN and she does an awesome job. If having an army more of her across the land means better access to mental health services for everyone, I say we do it.
currants
@Richard Mayhew: Yes–I’m aware of that, so I’ll be interested to see whether that stays the same or whether more men enter that profession, given the changes likely in public perception and the practical changes on the ground. (And of course the corresponding change in incomes in those professions: some will be a function of ACA impact, but there is also often a gender-related income change as well, at least in this country.)
currants
@Richard Mayhew: …and thus the argument/explanation for lower incomes for female etc etc etc. Blech.
currants
@Luthe: Where are you, geographically? I’ve been trying to scour up someone–ANYONE–who can do both psychiatric and Alzheimers for a relative in a rural area (NE PA, population ‘no roads in that town’) and–well, no luck.
JoyfulA
@currants: From what I’ve seen personally in central PA, NPs are female, and PAs are male.
There’s been fuss about NPs practicing independently in rural western PA; apparently MD supervision is charitably described as minimal, as is.
MomSense
This is a great thing. For most situations, NPs and PAs are more than adequate.
Richard, there was a story on MPBN this morning about rate hikes on insurance premiums in NH and Maine for next year. My insurer, Maine Community Health (a COOP) has asked for an across the board 20% increase. Their reasoning is that the influx of Medicaid patients are proving much more costly and making the pool more expensive to insure.
Ugh. LePage is the gift that keeps on giving.
currants
@MomSense: LePage –didn’t I read somewhere that he’s aiming to follow Kansas’ model for ‘success’ (not defined in a way I would define it)? Or was it Oklahoma? And why does this make me think of that line, “Nice state you got there. Be a shame if anything happened to it.” …?
MomSense
@currants:
Yeah he’s a menace alright. He said he will veto all Democratic sponsored legislation until they approve a constitutional amendment to get rid of state income tax. There’s also a kerfuffle about the PUC because a lawmaker dared make FOIA requests on his interaction with the PUC.
Jim
I also like this trend, although having the nearest “full” doctor seven hours away would make me a bit nervous. But here in the semi-rural Shenandoah Valley, CNPs and PAs are taking up more and more of the slack, doing jobs that are (appropriately) somewhere between nurses and doctors. I suspect the docs like them as well — at least mine does. A PA costs a practice much less than a partner doc, but still enables bringing in more patients…and profit.
There are some drawbacks. My doc had a PA intern for a few months, and my annual physical took place during that time. I was the proud recipient of not one, but two, prostate exams that day. One by the PA, the other by the doc to check her work. :-)
currants
@MomSense: Next election is when? My SiL is in last year of med school and Portland is (I think?) one possibility for residency (pediatrics). Fingers crossed for you (and him…and my daughter and their girls!).
The Raven on the Hill
@Beth in VA: “I have noticed more and more no doctor is available when we need an appointment, and the nurse practictionor does not get the diagnosis right.”
My experience with NPs and PAs is that they do not listen or diagnose well. Instead, they prescribe scattershot, and hope what they prescribe will help.
Great for the drug companies and insurance companies. The patient? Not so much.
Kay
My youngest broke his arm and it’s complicated- it’s a bad break and it’s close to his wrist so they’re watching for nerve damage. He’s been getting a lot of after care and I’m really pleased with the PA.
The PA seems to have more time, which isn’t a slam on the physician- I know they push them really hard to get in and out because they’ve complained about it to me- but it is great to have the PA.
I don’t know though- do physicians get in this to be case managers? Isn’t patient treatment, the contact, one of the reasons they became doctors?
MomSense
@currants:
2018
We’ve never had such terrible governance before. As it was Maine had a lot of challenges with a geographically huge state, small, older population. The basic problem is that we don’t have enough people to support the infrastructure needs of such a large state. Add to that high cost of living because of energy costs etc and I’m not optimistic about our ability to bounce back after LePage. Well the southern part of the state will be fine but the northern/western part of the state is screwed.
japa21
My PCP is part of a large family practice which has several doctors and a couple PA’s. One PA has been with them several years and when my PCP is not available for a quickly needed visit, she is the one that will usually see me. At my age, I have been to a lot of different doctors over the years and I would put her quality of care above many of the full doctors I have seen.
It should be noted that this midlevel of care provider still has restrictions placed upon what they can and can’t do and they, in general, do not get reimbursed even close to the full MD/DO level, but most of them do a great job.
The Raven on the Hill
@Kay: I’m glad to hear you are having a good experience with your PA. Managing treatment of a broken arm is a great job for a PA—diagnosis is easy and long term attention is needed. My last PA, dealing with a hearing problem, left me feeling like I was dealing with the sort of salesman who tries to sell you everything in the shop.
I think there’s a lot of people becoming doctors for the money these days, and who don’t care much about patients. There have always been some, but with medicine so lucrative, it’s become a norm. Insurance companies are entirely in it for the money—insurance is a financial service.
Beth in VA
@The Raven on the Hill:You’re right that it depends on the person and the situation. I’ve had good luck with PAs in the OB/GYN field, and horrible experiences when it’s internist-type medical issues for myself and kids.
Elizabelle
@Kay:
I am wondering if case management might be a good niche for physicians who are raising their own families. Maybe something they could handle via laptop from home, reviewing charts at less than full-time work schedule. Or even job-sharing.
Elizabelle
@MomSense:
Any of them wishing they could be Canadians?
Blue in SLC
I’m not convinced nurse practitioners and PAs will save money in the long run. Because they lack the depth of training and expertise that MDs receive, they tend to order more tests and refer to more expensive specialists, at least compared to internists (or other PCPs).
The PCP shortage is being driven by the inequity in pay between specialists and primary care, and the amount of paper work getting dumped on PCPs. Perhaps the masters level workers could handle more of the paperwork to help maximize the patient contact with PCP.
MomSense
@Elizabelle:
ay
Ruckus
@Jim:
And my MD at the VA was checked by a NP who specializes in urology. Wasn’t on the same day though. In the past I had my doc, who also taught at a medical school, and a 4th yr student do one right after the other in the same room. In medicine you learn by watching and then doing, someone has to have the doing done on them.
Ruckus
@Beth in VA:
@Blue in SLC:
The quality of the care is the person. I’ve had asshole specialists and wonderful docs, great PAs and NPs. But as someone who used to hire highly skilled craft workers I can tell you that this is no different than any other field. It becomes much more personal because they are working on you and the outcomes are somewhat more important, but the same concept of skills and personality are the same everywhere.
Some got it, some don’t. Management can help, retrain, restrain, fire, but management has the same problem, we are all flawed humans.
imonlylurking
A Nurse Practitioner saved my life. The MDs saw I was sick and prescribed antibiotics, repeatedly, for several years. The NP looked at my history, watched me for a minute or so trying to stop coughing long enough to speak, and diagnosed me with asthma.
In another, more depressing vein-I was diagnosed when I was 37. That means I will be 74 before I will have spent 50% of my life properly medicated for asthma.