An Rx for the doctor shortage

As of November, about 46,000 primary-care physicians were practicing in California, or about 120 per 100,000 residents. That ratio is misleading, however; though the availability of doctors is sufficient in urbanized counties, it falls off sharply in less densely populated areas.
(Christopher Serra / For the Times)

New subsidies and insurance regulations in the 2010 healthcare law are expected to bring coverage to millions of uninsured Californians starting next year. The newly insured are likely to put a bigger strain on the healthcare system, particularly in their demand for primary-care doctors, of whom there are already too few in many parts of the country. That’s why trained medical professionals who aren’t physicians, such as nurse practitioners, want more freedom to deliver the care they’re capable of giving than state rules allow. Lawmakers should give it to them.

As of November, about 46,000 primary-care physicians were practicing in California, or about 120 per 100,000 residents. That ratio is misleading, however; though the availability of doctors is sufficient in urbanized counties, it falls off sharply in less densely populated areas. In fact, as of 2008, nearly three-fourths of the state’s counties had a shortage of primary-care doctors.

There are two ways to address that shortage: by increasing the number of those doctors — as several provisions of the 2010 law seek to do — and by allowing more trained medical professionals to provide care that only doctors can provide today. These approaches aren’t mutually exclusive, and both are under consideration in Sacramento. But the former can be time-consuming and costly, and the latter is extremely contentious.

The biggest fight this year is over three bills by state Sen. Ed Hernandez (D-West Covina) that would allow optometrists, nurse practitioners (registered nurses with advanced training) and pharmacists to offer more primary medical care independently of doctors. While Hernandez, an optometrist himself, says he’d like to increase the number of doctors over the long term, in the short term he wants to “utilize licensed professionals to their maximum potential.” Physician groups object, arguing that the bills would allow less-trained professionals to prescribe and dispense drugs, make diagnoses and even perform some surgeries.

But the measures aren’t really that open-ended, nor should they be. The additional authority they would grant would be within the boundaries of the training and standards set by those professions. Pharmacists would be able to provide birth-control pills and smoking-cessation medicines without a doctor’s intervention, as well as vaccinations and tests that monitor the effectiveness of a prescribed drug. Nurse practitioners would be allowed to diagnose and provide treatment plans for patients with chronic diseases such as asthma or high cholesterol, as they do at Walgreens’ walk-in clinics in 18 other states. Optometrists would be permitted to diagnose ailments that can be detected in a patient’s eyes and, in coordination with an MD, provide primary care for those patients.


There’s at least one other significant benefit to expanding the duties (or “scope of practice”) of medical professionals: Unlike training more doctors, it can reduce the cost of medical care by allowing lower-cost workers to do more routine tasks in place of higher-paid MDs. Advances in technology enable workers with less training and experience to do more complex tasks in medicine, just as in every other industry. As Dr. Mark Smith, who leads the nonprofit California Healthcare Foundation, puts it, “We should not pay doctors’ wages to do clerks’ work.”

The challenge is figuring out just how much latitude to give medical professionals to deliver primary care independently of MDs. The California Medical Assn., a trade group that represents doctors, insists that non-physicians are already doing as much as they should. But the scope of practice limits set by California and most other states is based on a person’s professional credentials, not on actual capabilities.

Nurse practitioners, optometrists and pharmacists may not spend as much time with patients in the course of their training as would-be doctors do, but all have graduate degrees, and all receive much of the same basic instruction in science, physiology and medicine as doctors. Nurse practitioners already diagnose and treat patients daily, subject to the limits set by the medical group they belong to, just as optometrists are already trained to recognize diseases through symptoms in their patients’ eyes.

State lawmakers wouldn’t have to break any new ground if they were to expand medical professionals’ duties. More than a dozen other states have given professionals with advanced training more leeway to take specific steps without a physician on hand signing off on everything they do. California should follow their lead. More leeway should also be extended to physician assistants, starting with lifting the requirement that one MD be on duty for every four physician assistants working in a medical group.

All the same, the best approach is to give medical professionals more freedom to act in coordination with a medical team that can provide comprehensive care. With the advent of electronic medical records and online videoconferencing, there’s no reason licensed and well-trained medical professionals can’t do the same things in rural areas with a consulting MD on call that they do in a medical office building in the city. They would also have a powerful incentive to use their new latitude cautiously: They’d be liable for any problems that resulted if they practiced beyond their training.

Opponents argue that letting non-doctors perform more of a doctor’s duties would create a two-tiered healthcare system. But there are two tiers already: one that offers care, and one where no one is available to provide it. The quickest way to improve the situation is to let medical professionals do more of what they can do, and already are doing in many other states. It would also help keep the cost of treatment from climbing out of more Californians’ reach, regardless of how many doctors are nearby, without reducing the quality of their care.