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.