• Expanding the primary care supply

    There really isn’t much need for further comment on the idea of enabling nurse practitioners and other non-physicians to practice at the top of their training and to help meet the demand for primary care. It was the lead subject in yesterday’s Wonkbook. So, you could go read that. Just over a week ago Mike Miesen reported on the fate of California’s nurse practitioner scope of practice legislation for Project Millennial, where he has covered the issue before (and before that). So, you could go read that too.

    Suffice it to say, this is a well-worn idea, but a good one. Even if one believes that physicians would provide higher quality or safer care (and one must ignore some evidence to hold these views), primary care physicians are in short supply in some regions. Health reform will accelerate the strain on that supply.

    In light of these facts, for what reasonable, patient-centered reason should other health care professionals not practice at the top of their education and step into the breech? Is the argument that it would be better to see no health care professional or wait a long time to do so than to see a nurse practitioner for primary care? It hardly seems reasonable.

    In any case, Victor Fuchs agrees. In a new JAMA viewpoint, he wrote,

    The demand for primary care is strong and likely to grow stronger. It is, however, unwise to think that the demand could or should be met by an increase in the supply of primary care physicians. […] With proper organization, the majority of first-contact primary care could be met by an increase in the supply of nurse practitioners, physician assistants, and medical aides working under a “leader of a primary care team” who has been specially trained for such a role. Moreover, the leader’s compensation could and should be comparable with that of other specialists. Such leaders could, where appropriate, subspecialize into pediatric, adult, and geriatric care.

    How is this not a good idea? At the very least, why is it not worth trying in regions that are in clear need of more primary care? I acknowledge that some physicians may view this as an encroachment of their turf, unwanted competition. Nevertheless, for the good of patients, and the country, docs need to get out — or be pushed out — of the way on this one.


    • Of course it’s a good idea to increase the supply of those who provide medical services. Allow nurse practitioners to do more. Allow more non-US doctors to immigrate and practice medicine. Increase the size of medical schools.

      This will decrease doctor’s income. That’s a feature, not a bug, if our goal is to increase care and reduce costs. That’s why doctors fight any proposal to increase the supply of medical practitioners. It’s yet another reason putting doctors in charge of regulating the supply of doctors (e.g., through control of state licensing) is a mistake.

      • Nice theory, except that you’re WRONG.

        More doctors or “providers” ==> more diagnoses ==> more tests, more procedures ==> HIGHER costs, not lower.

        Take any region of the country and compare the number of doctors per capita one time point to the next. Even after you adjust for cost of living and technology innovations, costs always go up.

        If your theory was correct, Manhattan should have rock bottom healthcare prices. Manhattan has the largest number of doctors per capita in the world.

        BTW, you are also wrong about doctors “limiting any chance to increase supply.” There are over 50 new or planned medical schools in teh last 10 years. I’ll post a list of them if you like.

      • It’s a good idea for those who don’t value having a relationship with their Doctor.
        What’s next Drive Through Doctor Visits. This scheme come about not as an idea to improve Medical Care but to reduce the cost of Medical Care.

    • Milton Friedman couldn’t have said it better.

    • I think that an additional challenge to getting Nurse Practitioners to do more of the work is that there’s a tendency to pass the buck out of fear of malpractice liability. That is, practitioners and pharmacists can already do considerably more than they do, because they tend to refer patients to physicians for conditions they should be able to treat themselves, on the off chance that their diagnosis is wrong and it might be something worse. Primary care physicians also do this, referring patients with basic illnesses they can treat to higher-priced specialists, just to avoid liability in case their diagnosis is wrong.

      • This is correct, and it is why NPs and PAs INCREASE costs, instead of lowering them, despite the fact that they make less money than MDs.

        Consider this example:

        Scenario #1: 70 year old patient goes to a family practice MD. Gets diagnosed with diabetes. Starts on a diet reduction plan, metformin, etc.

        Scenario #2: 70 year old patient goes to a family practice NP. Gets diagnosed with diabetes. Starts on a diet reduction plan and metfomin. GETS REFERRED TO AN ENDOCRINOLOGIST.

        This is why NPs will never save money over MDs. They refer every patient to a subspecialist, and costs skyrocket as a result.

        • @platon20, unfortunately evidence does not support your hypothesis that a diabetic patient seen by an NP will cost more just because such a patient gets referred to an endocrinologist for management of diabetes.

          I work at a VA hospital, and we track lots of data. Some of data shows that primary care MDs and NPs who manage diabetics refer at equal rates. Furthermore, they refer seldom. This is because NP (at least at our VA) are fully capable managing complicated diabetes patients. This in turn because we work in interprofessional teams that include MDs, NPs, pharmacists, and a host of other professionals such as nutritionists, behavior specialists, etc. Of course we track A1c’s and all that jazz, and, no surprise, there are no differences in diabetic outcomes in patients who have NPs as their primary provider vs those who are followed by MDs.

          More, lectures to [MD and NP] trainees on diabetes management are given by NPs.

          • 1. You are wrong about referral rates. NPs refer at higher rates. See Jenks, Smith, Warren, and Byers’ papers published in Health Affairs.

            2. I’m supposed to be impressed by “lectures” by NPs on diabetes? I’ve been to these lectures, and they consist of “diet coaching” fluff.

        • Aside from ignoring the data, which Alpine provides, you make an unfounded assumption. You assume that an MD won’t (and don’t already) do the same thing.

          My personal experience (anecdotal) is that doctors routinely refer to specialists when not needed. Why do you think there are so many specialists? It’s a continual source of frustration for me. Referrals in general waste my time, my money, and decrease my well being.

      • What this scheme really is about is to patch flaws in the ACA. After all a nurse is just as good as a Doctor…Right?

    • I understand that expanding NP scope will likely be good for primary care access and quality, but what about cost? NPs usually get reimbursed at a lower rate than primary care docs, but I recently heard about a payment parity law passed in Oregon: http://www.oregonrn.org/displaycommon.cfm?an=1&subarticlenbr=670

      I was wondering what your general thoughts on 1) if these payment parity laws are likely to “catch fire” in other states, and 2) What might be the long-run cost implications of increased scope for NPs?

      • Good point.

        Why would I pay the same for a nurse when I can get a real doctor instead?

        P.S. Insurance companies charge the same to the patient regardless of whether they see an NP or an MD.

        • Because I can see them when I need them? Sometimes there is a choice between the doctor office, urgent care, or the ER. I’m more than happy to stick my insurance company with a massive bill if my doctor office can’t or won’t see me.

          Because a good, experienced NP and PA is better than a poor or average MD? Not unusual at all.

          Because they actually listen? Sometimes it’s good to have someone that’s open to listening. Why not up the medication before referring me. Write me a prescription to keep me out of the ER (now there’s a novel concept). Sometimes as a patient I actually do know more than the doctor. I have to live with my condition.

    • Just want to remind all that PAs also are clinicians who can provide primary care at the same level and high quality as physicians and NPs. We sometimes get lost in the conversations. Look at the military and the VA. We are doing much. Don’t go that far, go to the ER down the block.

    • Pharmacists are another underutilized health care professional. Pharmacists could do a lot more to ensure that medications are being properly used to achieve good outcomes, especially for chronic illnesses. Currently they are only paid for dispensing and not for clinical services, which limits the use of their patient-care training and skills.

    • Expanding access as an argument does make sense as an argument (even if its disturbing that no universal system does anything similar thanks to the obvious dangers involved once looser restrictions are in place).

      Reducing cost (or even salaries for physicians) as an argument does not. Several reasons why:
      1. Thanks to the ACA, NPs must receive equal reimbursement from payors. Thus, no savings flow through to the system and to patients/taxpayers/premium payors (providers get higher profit margins).

      2. NPs order more downstream imaging and specialist referrals once you control for case mix (internal health system data from a client NOT published) and especially once you factor in their liability. Thus, as a system, we have now added an extra layer of hidden cost.

      3. More providers = more cost (see this blog’s eloquent explanation of supply-induced demand and especially the evidence from S. Florida). If we at least lowered physician compensation, some doctor-haters amongst us might at least be happy but natural experiments with these supply increases (e.g., the entry of thousands of D.O.’s into the medical field in 70s) have shown us what theory would predict (i.e., no significant effect on physician salaries).

      If we want to cut doctors’ salaries, then we should do it directly (via CMS) rather than try these convoluted policies that only increase system-wide costs.