Obamacare isn't creating a doctor shortage, it's solving it
It's a myth that America doesn't have enough doctors. The key to the future of US medicine is to utilise more nurse practitioners
theguardian.com, Tuesday 28 January 2014 09.30 EST
Doctor and nurse
Nurse practitioners and physicians' assistants can help by serving as "physician extenders". Photograph: Christopher Thomond/The Guardian
No doubt you have read headlines like this one: "The Next Obamacare Debacle: A Massive Doctor Shortage." Before you panic, remember that reform's opponents are prone to exaggeration, and they are responsible for much of the fear-mongering surrounding this issue.
Granted, it is harder to ignore the American Association of Medical Colleges' (AAMC's) warning that in 10 years, the US will need 45,000 more primary care physicians (pdf). But you also should also take the AAMC's numbers with a grain of salt. It has a vested interest in increasing government funding for medical colleges. Secondly, its projections assume that most doctors will continue to practice medicine the way they have for the past 30 years. In other words, they are basing their predictions on a static model.
Fortunately, the Affordable Care Act (ACA) – more commonly known these days as Obamacare – lays the groundwork for extraordinary changes in how we deliver and pay for care.
First, Obamacare puts a new emphasis on team work, with nurse practitioners (NPs) and physician assistants (PAs) becoming part of the team. We don't need to train more MDs, say some doctors, we need to make physicians more productive by using NPs and PAs as "physician extenders". NPs and PAs are health professionals with graduate degrees, who are authorized to examine, diagnose and treat patients. When they work alongside doctors, they can free MDs to spend more time with complicated and difficult-to-diagnose cases.
Because the ACA has provided new funding, their numbers are growing. The American Academy of Physician Assistants expects 10,000 new PAs by 2020. Meanwhile, nursing schools have received stipends designed to train 600 new nurse practitioners (pdf) and midwives by next year.
According to a recent study, the ACA can cut the physician shortage in half by doing just two things. First, expanding nurse-managed Community Health Centers that serve low-income patients who now often receive their care in ERs. Second, reward medical homes where physicians, NPs, PAs, pharmacists, and nutritionists use electronic medical records to coordinate care. Typically they will use e-mails and telemedicine to stay in close touch with patients. If they succeed in managing chronic diseases – and keeping patients out of hospitals – they will receive bonuses.
Community Health Centers also rely on teams, and now serve 20 million patients annually. Under Obamacare, they are expected to double their capacity by 2015, serving many who now receive their healthcare in an emergency room.
You may have heard that under the ACA, emergency rooms soon will be overflowing with new Medicaid patients who can't find a primary care physician. As evidence, Obamacare detractors like Forbes' Avik Roy point to a study of what happened in Oregon after it expanded Medicaid. In fact, the study is based on old, 2008 data. Since then, Oregon has cut ER use, in part by stationing community health workers in ERs to divert less urgent patient to community health center. From 2011 to 2013, ER spending in Oregon's Medicaid program fell by 18%.
Going forward, reformers hope to make greater use of NPs both in the field, and running their own community health centers. But today, many of the nation's 106,000 nurse practitioners, including about 56,000 who practice primary care, remain hemmed in by state laws that limit what they can do. At the end of 2012, nurse practitioners in only 18 states (plus the District of Columbia) could treat patients and prescribe medications without being supervised by a doctor. The Institute of Medicine argues that, if we want to improve healthcare states "scope of practice" laws for NPs must change.
But not everyone agrees. The American Medical Association argues that encouraging patients to see NPs may put patients at risk. The AMA emphasizes the difference in education – four years of medical school plus three years of residency for doctors compared to four years of nursing school and two years of graduate school for nurse practitioners.
However, NP advocates point out that, unlike MDs, NPs spend their training time focused on the clinical area where they will practice. When they enter (pdf) a NP program, they pick the patient population that they wish to work with. For instance, some choose to become Pediatric NPs. From that point forward, all coursework and clinical education is focused on issues related to the development and healthcare needs of children. By contrast, a doctor who winds up becoming a pediatrician spends much of his time completing rotations in many unrelated areas.
Advocates also note that because it takes nurses an average of six years to complete their training, compared to an average of 11 to 12 years for physicians, we could fill the growing primary care gap more quickly by training more NPs.
But will the quality of care suffer if nurses provide more primary care? Medical research says "no".
In May 2013, Health Affairs reported that "a systematic review of 26 studies published since 2000 found that health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians." Surprisingly, patients seeing nurse practitioners also were more satisfied with their care. The studies suggested that when it comes to tending to patients, nurse practitioners do a better job:
The patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.
Finally we should realize that, to a large degree, the perceived shortage of doctors can be attributed to uneven distribution: 20% of Americans live in areas where there are too few PCPs. And minting more new MDs is not the solution. As this table reveals, medical school graduates will continue to flock to the wealthiest states: few are eager to set up a practice and raise their children in rural Mississippi.
But the ACA addresses the problem by providing $2bn in new funding for the National Health Service Corps (NHSC), a government program that offers scholarships and forgivable loans to healthcare workers willing to "go where no one else will go." Over five years, that sum should create more than 12,000 new PCPs, NPs and PAs – yet another example of how Obamacare isn't "creating" a doctor shortage, it's solving it.