One of the most widely discussed challenges in the wake of health care reform has been the physician shortage, and more specifically, a shortage of primary care physicians. With millions of newly insured patients under the Affordable Care Act and an aging population, analysts fear that a strained health care infrastructure will soon crack under these new burdens.
Policymakers have scrambled to find ways to increase the availability of health care providers. A popular proposal has been to increase the autonomy of midlevel providers, like nurse practitioners.
Last month, New York and Connecticut passed legislation allowing nurse practitioners to practice without physician oversight, joining 16 other states that already do so. Advocacy groups have pushed for similar legislation in California over the past few years. Unfortunately, such legislation may fail to increase access to care and could ultimately exacerbate the physician shortage it seeks to address.
First, some background. Nurse practitioners are a type of advanced-practice registered nurse who have earned a master’s or doctorate in nursing. At present in California, nurse practitioners perform many of the same functions as primary care physicians, including diagnosing patients and prescribing treatment.
However, they must do so according to standardized protocols developed in conjunction with a supervising physician. The supervisor must also be available for consultation when the nurse practitioners see patients, although “supervision” can be as simple as being a phone call away.
Legislation under consideration in many states would eliminate this requirement. Advocates argue that increasing nurse practitioners’ scope-of-practice would increase access to care, as nurse practitioners are more likely to work in traditionally underserved areas and accept Medicaid patients. Moreover, several studies suggest that nurse practitioners provide a similar standard of care as primary care physicians.
Even so, there are two major reasons to remain cautious about scope-of-practice expansions. For one, removing the need for physician supervision is unlikely to change the number of patients seen by nurse practitioners. They already act independently for the most part. Complete autonomy would not let them see new patients if they have a full patient workload. And if nurse practitioners are not going to see new patients, it makes little sense to eliminate remotely available guidance from more highly trained health professionals.
The second, and potentially more significant, consideration involves the future of the primary care physician. Even the most vocal proponents of nurse practitioners’ independence agree that the underlying problem is a physician shortage. They argue that because there are not enough physicians, we should rely on nurse practitioners.
Yet passing these measures will change the landscape of the primary care workforce over time and could reduce the number of physicians. A survey of fourth-year medical students published in the Journal of the American Medical Association found that the proportion of medical students planning to pursue a career in general/primary care internal medicine dropped by about 75 percent between 1990 and 2008. As other providers take on the responsibilities that used to be held by doctors, interest will drop further.
It would be alarmist to claim that the primary care physician will soon disappear, but consider the perspective of a medical student: why would he or she want to go into a field where people with less education and training do the same job?
Moving forward, we are faced with two contrasting approaches to primary care. One option would be to allow midlevel practitioners to take over as gatekeepers of the health care system. However, this raises concerns about quality of care, especially for complex cases. If policymakers intend to solve the physician shortage, they should instead use a three-pronged approach to make physicians available: increase supply, increase productivity and decrease demand.
To increase the physician supply, states could fund schools that emphasize primary care and provide financial support to students who pursue it. Schools may also develop accelerated programs for students interested in primary care.
Along with increasing physician supply, we should improve physician productivity. For instance, communications technology (i.e. telemedicine) can expand the geographic reach of physicians. The existing California physician shortage does not stem from absolute numbers of physicians so much as the distribution. Telemedicine is a mechanism for redistribution.
Lastly, preventive care measures can help reduce the demand for physicians, thereby relieving the load on the health care system.
To solve the physician shortage, policymakers must foster coordination between physicians and other providers. Creating overlapping scopes-of-practice generates competition and discord, and will ultimately backfire on the purpose of these policies.
Akhilesh Pathipati is a Stanford medical student and Harvard graduate who has worked on health initiatives in Massachusetts and California. He is a Sacramento native.