Huge Solutions to Problems of Primary Care Shortage
Sunday, August 18, 2013 • 9:35pm
It used to be the case that health planners had been forecasting impeding physician surpluses, and policy decision related to medical schools and residency programs have been based on such expectation. Today, there is much less surplus, in fact never materialized surplus, and a growing body of opinions floating in the other direction. The question at the forefront is whether the United States is instead headed for a physician shortage? I assess that the current environment through examination of trends in the characteristics of clinical practice, signals from the medical market, and recent preferences of physician shortages in other English-speaking countries.
Health care spending 2.5%
Health care labor force Additional lag in staffing after changes in economy 2.2% Physician supply Additional annual percentage changes in private health expenditures. There is also a cascading dimension to this argument that is self-evident or this pressure to do more. We also see that many forces contribute to an upward pressure on health spending. One is efficiency gains or technology. Heavy investment by both the National Institutes of Health and the private sector ensures that the continued development of technical, and public support welcomes its products. But efficiency gains are not used just because they exist. When you talk about healthcare reform and what is expected to happen as far as people having more coverage, there is going to be more people needing care. Therefore, a process of sifting and debate ensues in which efficiency gains is purchased to the extent that funds are available. This is probably the most visible example of the three steps to beneficial supply of how our society struggles to determine what it can spend.
Internal Differentiation and the Problem of Power:
To see professionals, and particularly professional firm, within a wider ecological system is to understand that the professions constantly changing is disconcerting.
In terms of NP’s contributions to culturally competent care, advocates for patients, hospitals and insurers agree that allowing nurse practitioners (NPs) to fill in for doctors makes sense when it comes to basic services. But physician groups vigorously oppose the changes arguing that nurses lack the training to safely diagnose, treat refer to specialists, admit to hospitals and prescribe medications for patients, without a doctor’s oversight. But where is the potential then? We are not talking about protecting what physicians do, this is about protecting patient safety. Concern should be that this push for expanded scope of practice is in some ways a way to try to practice medicine without getting an M.D. degree.
The potential for variation comes down to an population ever more so in outcomes means that ever since the Affordable Care Act was passed, hospitals are beginning to recruit every provider that they can get their hands on, including nurse practitioners and physician assistants. It makes it very hard to compete when an organization with deep pockets pays more.
The most common criticism of Direct Primary Care is that if you substantially reduce panel sizes, this markedly exacerbates the primary care shortage in this country unless there is at least a 2-4x increase in the number of PCPs being trained. This is a particularly significant issues for nurses who tend to have longer consultations than doctors, and patient satisfaction is higher with longer consultations. Nurses also tend to provide more information to patients than do doctors which might also have enhanced satisfaction results. However, high satisfaction with nurse care does not mean that patients inevitably prefer nurses to doctors. In fact, patient preferences in most cases are mixed with some patients preferring to see nurses while others prefer to see doctors. Productivity is lower when nurses, as opposed to doctors, provide first contact for people wanting urgent attention. It therefore seems unlikely that the lower productivity of nurses as compared with doctors reflects their relative inexperience. There is a reduction in the demand for doctors in which nurses provide first point care for patients wanting urgent attention out-of-hours. We cannot lose sight of the fact that the addition of nurses to physician teams may not reduce workload unless active steps are taken to ensure doctors discontinue providing the services that have been transferred to nurses. Another reduction or impediment to expanding physician supply is this notion that physicians case health care utilization. False. Supplier-induced demand seems to have a small and inconstant effect to overall health care spending. Thus the question is whether limiting the supply of physicians is a valid approach to constraining health care spending or whether doing or simply decreases quality and creates obstacles for the neediest patients. It is my estimation that this becomes not an issue for a young healthy person with a minor problem, but possibly lethal for older complicated patients with multiple chronic diseases.
There is a very real role for nurse practitioners in closing the gap, particularly for patients who need preventive health care and patients who do not have complex illnesses and who relate well to primary care providers. For example, patients at NP-led clinics register to the clinic itself and are not restored to a physician. The advantage to the patient is seen when a healthcare provider leaves. A new provider for example, is hired and the patient continues to belong to the clinic and receive primary healthcare services. But, physicians as well a state and federal lawmakers are increasingly putting patients at risky by allowing lesser-trained nurses, specialist and other limited licensure practitioners to encroach into areas of healthcare where they are not qualified to provide patient care. Still, appropriately trained nurses can produce as high quality care as primary doctors and achieve as good health outcomes for patients. Indeed nurses providing first care for patients needing urgent attention tend to provide more health advice and achieve higher levels of patient satisfaction compared with doctors. Nurse-doctor substitution has the potential to reduce doctors’ workload. But, this benefit will not be realized in practice if doctors continue to provide the types of care that have been transferred to nurses. I ask myself, wouldn’t fewer physicians be needed if the existing differences could be eliminated? While health care is imperfect and offers countless opportunities for improvement, its long-term growth is governed by the pace of economic expansion. I foresee future healthcare remaining dynamic and somewhat unpredictable, particularly the political dimensions. However, one can reasonably expect massive competition and innovation, care to be provided closer and closer to home, the income disparity between specialists and primary care physicians narrowing, fee-for-service waning, and healthcare going to be subjected to deflationary pressures as private and public sector budgets are unable to support the current levels of spending. Two state bills passed in 2013 strengthen nurse practitioners’ duties. One extends the amount of time nurse practitioners can treat workers compensation patients from three months to six months, and another ends restrictions on nurse practitioner dispensing. Previously, nurse practitioners had to prove there was inadequate pharmacy services in their area before they could dispense.
For more on state variation in scope-of-practice laws governing nurse practitioners go to:
The 2012 Pearson Report: A National Overview of Nurse Practitioners Legislation and Health care Issues at http://www.pearsonreport.com/tables/maps/category.2012-introduction/
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