Friday, March 29, 2013

Physicians, Nurses, and the Future of Healthcare

The number of people scheduled to obtain some form of health insurance is in the millions. We also have a greater fraction of our population moving into the post-retirement phase of their lives when medical care needs increase. Some have interpreted this situation to mean that this will result in a shortage of doctors. That is the wrong interpretation. We already have too many doctors and our healthcare system is burdened by the need to provide the lofty fees necessary to cover their income demands and the overhead they create. We don’t need more doctors; we need to develop practices that make better use of their skills.

The traditional approach where the patient endures a sequence of 10 minute sessions with a personal physician in his office while the physician tries to figure out what is going on is no longer acceptable. A different form of care is required, particularly for the elderly and those with one or more chronic conditions. These are the people who generate the large medical bills. These patients need a more extended and intense interaction with caregivers than a doctor can provide.

The solution is for as many responsibilities of doctors to devolve to care givers who can spend more time with patients. Just having someone who will verify that patients are following their doctor’s orders would improve efficiency greatly and lower net costs. These workers would have an appropriate level of training for the activities they participate in and they would be paid at a lower level than physicians.

In 2010 the Institute of Medicine (IOM) issued a report studying how nurses might best be used in our evolving healthcare environment. It produced these recommendations:

"Nurses should practice to the full extent of their education and training."

"Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression."

"Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States."

This was clearly a call to allow nurses to assume a greater role. The IOM report also presented evidence of the efficacy of allocating more responsibility to nurses based on experience involving the Veterans Affairs Department (VA) when that agency was faced with a large influx of new enrollees. An article in Modern Healthcare provided this summary:

"In response, the VA moved away from a system of hospital-based acute care and toward community-based delivery emphasizing primary care and chronic-disease management—roles filled by registered nurses and skilled nurse practitioners, the IOM said."

"The result? Studies showed that higher proportions of veterans received appropriate care relative to comparable Medicare enrollees, and spending per beneficiary rose more slowly—30% cost growth for VA patients between 1999 and 2007, compared with 80% for Medicare beneficiaries over the same period, according to the Congressional Budget Office."

This is the path recommended above; it provides better healthcare outcomes at a lower cost.

Since the report was issued pressure has been placed upon nurses to upgrade their educational credentials, presumably in order to assume a more responsible role. Meanwhile, the doctors unions and their lobbyists have been out there trying to suppress competition by limiting the roles available to nurses in hopes of preserving the lofty incomes and privileged positions that doctors have been enjoying.

An article by Shannon Pettypiece in Bloomberg Businessweek, Nurse Practitioners, Doctors in Tug-of-War Over Patients, provides some context.

"Nurse practitioners must complete a master’s or doctoral program in nursing practice—which adds two years or more beyond the four years of school required to become a registered nurse and includes training in diagnosing acute and chronic illnesses, pharmacology, and health-care ethics. Depending on the course of study, they can provide basic primary care or specialize in such fields as pediatrics, women’s health, or cardiology. They do not typically perform surgery or invasive procedures such as colonoscopies or tumor biopsies."

Pettypiece builds the article around the experiences of Christy Blanco, a nurse practitioner who has invested in gaining a nursing doctorate and in setting up a clinic focused on low income women. She has been unable to begin practice because the physicians’ lobby has installed restrictions that require nurse practitioners to have doctor oversight.

"Christy Blanco’s health clinic is sitting empty. A nurse practitioner in El Paso, Tex., Blanco says she has all the necessary equipment and a doctorate in nursing practice that prepared her to perform routine physical exams and treat diabetes, asthma, high blood pressure, and many other common ailments. About 50 miles away in Las Cruces, N.M., dozens of nurse practitioners at clinics like Blanco’s are busy caring for patients. The only difference is that in Texas, nurse practitioners are required to contract with a doctor to sign off on medical charts; the physician must also spend 1 out of every 10 days at the clinic. In New Mexico, no doctor is necessary. "I just want to get started," says Blanco, who’s tried for nearly two years to recruit a physician for her clinic, which will specialize in care for low-income women. ‘I’m trying to work for the poor,’ she says. ‘I’ve spent thousands of dollars of my own money. I have a waiting list of patients, and I have to tell them I can’t practice’."

There are about 155,000 nurse practitioners caught in a battle with physicians over who has access the cash crop of patients.

The situation is made murky by a disparate collection of state laws and restrictions.

"States regulate how much oversight nurse practitioners must have. In 16, including Colorado, New Hampshire, and Washington, they can evaluate and diagnose patients, order diagnostic tests, and prescribe drugs. That means they can start a practice or work out of a clinic with no doctor on staff. The remaining states have a patchwork of regulations. In Florida and Alabama, nurses can’t prescribe certain drugs for pain, insomnia, or attention deficit disorder that are considered controlled substances. In New York, they need a written collaboration agreement with a doctor, and there’s a limit on how many each doctor can work with, effectively creating a cap on the number of nurse practitioners."

Doctors may have political clout, but they have little data to support their arguments.

"Elizabeth Dears, a senior vice president for the Medical Society of the State of New York, said in testimony to lawmakers that removing doctor oversight of nurse practitioners "would seriously endanger the patients for whom they care." This claim, echoed by lobbyists for doctors in other states, is contradicted by at least two high-profile studies. A 2009 report by Rand Corp. found no evidence that nurses provide lower-quality care. A 2010 study of nurse practitioners published by the Institute of Medicine, a division of the National Academy of Sciences, recommended an end to state laws requiring doctor supervision."

The states seem to recognize the lobbying for what it is: an attempt to preserve an unnecessarily high healthcare cost burden on them.

"New York Governor Andrew Cuomo intends to do away with doctor collaboration agreements for primary-care nurse practitioners. Lawmakers in at least 10 other states, including New Jersey and Massachusetts, are considering legislation that would allow them to operate independently."

This is serious business. Our nation is in danger of collapsing under the burden of unnecessarily high medical costs. To fix this, everyone has to do their share—including physicians.


  1. Excellent piece! I love all of your writing and desire to learn -- it's infectious!

  2. Thanks for the kind and encouraging words. I can't tell you how interesting it has been to work on these articles. It has also been a lot of fun.


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