Votes are still being tallied in some races across the country, but for the most part, election season is over. There’s a new Republican majority in the House of Representatives, and they’re looking for a fight – a healthcare fight. Earlier this week, soon-to-be House Speaker John Boehner filed a brief challenging the constitutionality of the Obama Administration’s Affordable Care Act.
But the 32 million Americans who would receive access to healthcare from the reform bill have more to worry about than Boehner and the Republican party. There’s currently a shortage of primary care physicians in some areas of the nation, and it’s about to get worse.
THOMAS BODENHEIMER: The shortage is, is becoming nationwide.
That’s Thomas Bodenheimer, adjunct professor at UCSF’s Department of Family & Community Medicine. He’s one of the nation’s leading scholars in the primary care workforce. We spoke with him a few months ago. This is what he had to say:
BODENHEIMER: There are areas that are what we call “primary care shortage areas.” And those areas are now expanding. By 2020, there will be about 40,000 adult primary care physicians too few in this country.
That’s pretty dire. But listen to this: the Association of American Medical Colleges recently revised its shortage forecast from 40,000 to 60,000 needed physicians by 2015. In case you weren’t paying attention, that’s a lot worse. So you might be wondering: who’s going to take care of us?
Well, the National Academy of Sciences’ Institute of Medicine has a solution: nurse practitioners. A recent report by the Institute said that giving nurse practitioners a greater and more independent role can help the nation adapt to the changing healthcare system.
KALW’s Erica Mu reports on that controversial conclusion.
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ERICA MU: In the world of medicine, primary care often comes off as the earnest, unsung hero.
BUDD SHENKIN: Everybody needs primary care.
That’s Budd Shenkin. He provides primary care in the East Bay at Bayside Pediatrics in Oakland.
SHENKIN: You need to be cared for. Computers are great, the Internet is great, but you need somebody to guide you, help you and give you care – to put his or her hand on your shoulder, or to listen to you and to really care about you.
LAURA MILLER: I think it's amazing to be in a profession where you're right with people at their most important moments.
That’s Laura Miller. She also provides primary care in the East Bay, at the Richmond Health Center.
MILLER: You're there when people find out they're pregnant, you're there when they're in the process of dying or grieving lost family members. It's also a privilege to be a part of patients' families and to get to know them so well.
Shenkin and Miller both love their jobs. But they’re not exactly on the same team when it comes to what primary care should look like. How come?
Well, it’s this thing that keeps happening during Miller’s appointments.
MILLER: I am called doctor nonstop. And I think it reflects that I'm helping people as a healer. And the phrase "doctor," culturally, means healer. So I understand that, and I let patients know I'm not your doctor, I'm a family nurse practitioner.
There it is – Laura’s not a doctor.
MILLER: I explain to my patients that I can take care of them and meet all their needs for primary care by being a nurse practitioner. That I did not need to go to medical school to meet their needs as a family nurse practitioner.
According to a study published in 2000 by the Journal of the American Medical Association, care given by nurse practitioners is just as good as care given by physicians. That’s a study a lot of nurse practitioners refer to when they say they can help fill the impending doctor shortage.
Ah, the impending doctor shortage, or rather, the shortage of adult primary care physicians. You might not feel it now, but with an aging population and 32 million newly-insured Americans entering the system, you’ll probably feel it soon. Only 7% of fourth-year med school students are planning careers in adult primary care – a supply problem that’s been described by none other than NPR’s “All Things Considered” as a potential crisis.
ROBERT SIEGEL: The U.S. is facing a potentially catastrophic shortage of primary care doctors and other health professionals…
JULIE ROVNER: Well, doctors who are in training are going into every field except primary care, according to a report earlier this month in the New England Journal of Medicine.
In contrast, over 85% of nurse practitioner graduates enter into primary care, and they usually stay there: two-thirds of the 135,000-plus nurse practitioners across the nation are currently in primary care.
http://kalwnews.org/audio/2010/11/18/primary-care-turf-war-could-nurse-practitioners-play-role-doctor_696789.html - _ftn4Most importantly, a fifth of these nurse practitioners work in rural areas – places that are already hurting from a physician shortage. Places like Modesto.
MATT FREITAS: We're in Modesto, California, and the practice is Aspen Family Medical Group of Modesto. My name is Matt Freitas, I'm a nurse practitioner and physician’s assistant.
It’s 8 a.m. at the clinic in Modesto, but the waiting room is already full. Freitas says that Aspen Family Medical Group takes everyone, whether or not they have insurance.
FREITAS: Twenty percent of the patients we see, we see for free, everyday.
And it’s believable – the clinic is housed in a large strip mall where the 99 Cent Store is only two doors down from the Dollar Tree. And by the looks of the waiting room this morning, the clinic’s services are appreciated by members of the local community.
Members of the medical community, however, aren’t Freitas’s biggest fans.
FREITAS: They've made complaints to hospitals about me. I have staff privileges at one of the hospitals here, and there were complaints made against me.
Physician complaints against Freitas reflect a larger turf war in primary care, and clinics like his are the battleground. Aspen is the largest nurse practitioner-owned clinic in the state – sort of. Freitas owns 49% and not a bit more because in California, practices must be led by a physician. It's different in different states – if we were in Washington, Freitas wouldn’t have to collaborate with a physician to run a clinic – he could diagnose, treat and prescribe on his own.
KEVIN GRUMBACH: The politics get pretty thick.
Dr. Kevin Grumbach is a practicing physician and professor in Family & Community Medicine at UCSF.
GRUMBACH: So I think from the physician community, there are some that, you know, "Don't let a nurse practitioner at all encroach on our turf."
That sensibility goes right to the top. Joseph Heyman, former chairman of the board of the American Medical Association, was quoted last year as saying, “Non-physician health care providers serve a vital role on a physician-led health care delivery team. However, the health and safety of patients is threatened when health care providers are permitted to perform patient care services that are beyond their level of education and training." End-quote. Just last week a staff editorial from the American Academy of Family Physicians said:
ACTOR (reading from editorial): “…These personnel are an essential component in ensuring patients receive timely and quality health care, but they are not qualified to lead the medical home as independent practitioners.”
Which brings us back to the first guy we heard from this story.
SHENKIN: My name is Budd Shenkin, I'm a pediatrician at Bayside Medical Group. I've been a pediatrician for over 30 years.
He also spent six years heading a program in the U.S. Public Health Service, attended Yale University, the U.C. Berkeley School of Public Policy and the Stockholm School of Economics. And he thinks money in the medical industry is going to all the wrong places – to wasteful hospitals and clinics, to greedy insurance companies and to overpaid specialists, which means that med students aren’t incentivized into primary care.
SHENKIN: We shouldn't say, "Okay, we can't afford doctors in primary care, therefore we're going to have more mid-levels." That doesn't make sense. We've been historically based on doctors, and I believe in doctors.
MILLER: He's probably practicing in 1950's medicine (laughs) …
Again, Laura Miller of the Richmond Health Center.
MILLER: …We have a burgeoning population that is suffering because they don’t have access to healthcare, and it's available. Our patients are suffering because of these demarcations, and they're artificial.
Miller’s viewpoint is backed by the Institute of Medicine, which came out with a report in October supporting increased nurse practitioner autonomy. But for policymakers, what might be most convincing is the savings. According to a RAND Corporation study, expanding mid-level responsibilities could mean healthcare savings of $8.4 billion by 2020. That’s based on the assumption that nurse practitioners provide comparable care – something some physicians will readily admit.
MICHAEL ZIMMERMAN: They probably could take care of 85% of what the doctors can take care of and often better.
Michael Zimmerman owns his own small, private practice in Oakland. He’s not really advocating for independent nurse clinics. But he does think that nurse practitioners would work well as the frontline of preventative care.
ZIMMERMAN: By using care team members, physician extenders, to take care of work that can be done outside of the visit, that actually frees the visit up for a much more meaningful encounter. We are all for the use of anyone and everyone to deliver care, including patients themselves. I think it's how they all work together that's essential.
“Working together” may not be the revolutionary answer some nurse practitioners are looking for, but UCSF Professor Kevin Grumbach sees it as a fair compromise that shifts the role of both nurse practitioners and doctors.
GRUMBACH: Who we are in primary care and what we're trying to accomplish – It's no longer this iconic one family doctor who can do everything and is going to give the shots and do a little minor surgery and deliver the baby and then run off to the hospital for the person who's just had the heart attack and then hold your hand in the office. It's actually going to be a team that has to do that.
The limitations on nurse practitioners are still up to state policymakers, but the federal Department of Health and Human Services recently awarded $15 million for nurse-managed health clinics and $31 million in grant money to nursing schools. And if you’re one of the 94,000 patients who will receive access to healthcare because of the grant money, you very well may find that your primary caregiver is not a doctor, but a nurse practitioner.
For Crosscurrents, I’m Erica Mu.
