California doesn’t have enough doctors.
By 2025, the state will be short about 4,700 primary-care physicians, according to a recent report from the UC San Francisco Healthforce Center. This will result in more people turning to costly emergency-room visits for routine care, it predicts.
One solution is to expand the role of well-trained nurse practitioners, who can meet the basic healthcare needs of our growing population at a fraction of the cost of doctor visits. That’s what many other states are doing.
But this obvious remedy is opposed by a powerful interest — doctors. As a result, the Legislature has repeatedly failed to give greater independence to nurse practitioners, or NPs for short.
I wasn’t even aware of this issue until I stopped by a CVS MinuteClinic the other day to get my annual flu shot (which you should do as well; about 36,000 people in this country are killed by the flu every year).
The clinic’s nurse practitioner and I chatted as she prepped my injection. I asked if she could do most things a doctor could do. Could she prescribe medicine?
Yes, she replied, she could prescribe meds and do pretty much everything a family practitioner can do.
So why aren’t there more clinics like the one at CVS, serving as the affordable front line in our battle for wellness?
“The law doesn’t allow it,” she answered.
Theresa Ullrich, president of the California Assn. for Nurse Practitioners, clarified that the law does allow for greater use of NPs, but it contains language that makes an expanded role challenging if not impossible.
“We’re a good answer to the need for cost-effective and high-quality care,” she told me. “But we’re hamstrung by the state’s regulatory language.”
First, many people might not know the difference between a nurse and a nurse practitioner. In California, a registered nurse needs at least an associate’s degree in nursing, which takes about two years to obtain, often from a community college.
A nurse practitioner, meanwhile, must have at least a master’s degree and must receive advanced training in his or her specialty, such as family medicine. Unlike a nurse, a nurse practitioner can order tests, diagnose medical problems and manage a patient’s overall care.
Think of an NP falling between a nurse and a doctor. The typical nurse practitioner receives up to eight years of postsecondary education, whereas a doctor receives an average 12 years of postsecondary education and training, often more.
An NP focuses on wellness — keeping patients fit and addressing routine medical needs, such as checkups and health-maintenance programs. More complicated issues would require a doctor’s care.
For years, healthcare advocates have been pushing for a greater emphasis on nurse practitioners, and that makes a lot of sense. Many medical issues don’t require the expertise of a physician.
NPs, who earn about half what the typical California doctor makes, are in a position to offer treatment at a much more reasonable cost.
The problem is a state law requiring all drug-prescribing nurse practitioners to have a “supervising physician,” even though this doctor might play little if any role in the NP’s day-to-day practice.
“If I opened my own clinic, I would need a physician to supervise me,” Ullrich said, “and I’d need to put him on the payroll.”
The law also stipulates that each supervising physician oversee no more than four nurse practitioners.
“So if the clinic was going to expand,” Ullrich said, “I’d have to bring on more supervising physicians, and I’d have to pay them as well.”
The California Medical Assn., which represents doctors, insists that patients benefit from having physicians oversee nurse practitioners — even if a doctor isn’t physically present or isn't terribly engaged with an NP’s activities.
“Physician-led, team-based care is one of the best avenues to quality, low-cost healthcare,” Joanne Adams, a spokeswoman for the trade group, said in a statement.
She cited the “collaborative relationship between physicians and other healthcare practitioners,” and her organization’s support for “efforts to expand the productivity of these teams.”
That’s a lot of team spirit. But it’s hard not to suspect that doctors are just trying to make sure they keep getting a piece of the action for relatively little work.
Nearly two-dozen states have waived the requirement that nurse practitioners have a supervising physician. More than dozen others allow NPs to diagnose and treat patients (but not prescribe drugs) on their own.
California is the only Western state that still requires a supervising physician for nurse practitioners to diagnose, treat and prescribe medicine for patients.
“I could move to Nevada or Oregon and open my own practice without having to pay a physician to oversee what I’m doing,” Ullrich said.
State Sen. Ed Hernandez (D-West Covina), an optometrist before he turned to politics, has introduced bills seeking to follow other states in granting NPs more freedom. Each bill has collapsed amid fierce opposition from the doctors lobby.
“Organized medicine — the California Medical Assn. — doesn’t want anyone infringing on their business,” Hernandez told me.
He said there’s no evidence that giving nurse practitioners more latitude to practice medicine endangers the public or undermines the integrity of the healthcare system.
“In fact, there’s decades of evidence showing that they’re safe and that patients like them,” Hernandez said.
He emphasized that for many rural and inner-city communities, NPs may be the only healthcare providers willing to open local clinics and to take Medi-Cal.
While a third of Californians rely on the state-federal insurance program for coverage, a recent study found that 36% of California doctors refuse to see Medi-Cal patients because of relatively low reimbursement rates.
The state has a population close to 40 million people. By 2050, California could have 50 million residents, according to the Public Policy Institute of California.
Not having enough doctors to meet the healthcare needs of that population is frightening.
Not taking steps to address this shortfall with a greater number of nurse practitioners is simply foolish.
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