Posted on | October 25, 2012 | 4 Comments
With the election just two weeks away, the status quo as a choice- whether it be Grover Norquist tax pledges, Congressional stalemate, underwater municipal bonds, or a century old health delivery model – would seem unwise in the extreme. Were we as a country to chose it, we would live to regret it. Why? Because the status quo has been overtaken already by irreversible trends that gain more steam, day by day.
Regardless of who wins the election, we will be forced to evolve one way or another. And many of our citizens are not waiting for permission. Let’s take health care workforce issues as an example.
One of our valued Health Commentary subscribers wrote this week:
“Dr. Magee, just wanted to say thanks for the article.(1) I am an RN now and in school to become NP in about year and a half. I’ve read your article, and it gave me even more confidence that I am doing the right thing for my patients, my family and myself. The Affordable Care Act will create high demand for quality primary care, and I saw this as an opportunity to grow in the field that I enjoy. There is no doubt in my mind that “new” health care reform will, most definitely, require more NP in the field. I am still not sure how the ACA will be financed and who will end up paying for increased expenses, but one thing I know for sure; nurse practitioners (NP) will play a vital part in health care system in a few very short years.”
The air has been thick of late with articles about an impending doctor shortage – especially primary care doctors. But for leading nurse practitioners, the current conditions spell opportunity not threat.(2) Take Patricia Dennehy RN NP for example. She is the director of GLIDE Health Services in San Francisco and a professor at the UC San Francisco School of Nursing. Here’s what she has to say: “Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.” (2)
Why the focus now? Because the Affordable Care Act will bring an additional 30 million uninsured Americans into the ranks of the insured within the next two years.(3) There are already about 250 Nurse Practitioner run sites like Patricia Dennehy’s with varying levels of reimbursement and independence and/or cooperation with physicians.(2) The Institute of Medicine in its 2010 “The Future of Nursing” report, endorsed the use of nurses as “full partners, with physicians and other health care professionals, in redesigning health care in the United States.”(4)
President Obama’s Affordable Care Act arguably signaled that the status quo in health delivery was no longer acceptable. This was not the result of politics or a desire for social engineering, but a reflection of changing dynamic forces reshaping an out-of-date sector.
The three key trends that outpaced our delivery system were an aging population (with resultant 4 and 5 generation family complexity), Internet connectivity (and the capacity to built new virtual networks at low cost), and health consumerism (and its ability to emphasize personal resposibility and place individuals at risk for poor health behaviors). The end point? Personalized, prospective, and preventive health care.(5)
Of the many challenges this end point entails, none is more serious than human resources – creating a affordable and efficient workforce that is up to the task. This likely will require new job descriptions for every caring professional including the physician, massive retraining of existing workers, and critical re-thinking of workforce plans for new entrants into the various health care fields.
As health policy expert John K. Iglehart outlined in a 2011 article in the New England Journal of Medicine, health care human resource issues are rapidly coming to a head.(6)
Physician organizations say we need more doctors. The Association of American Medical Colleges says we’ll be short 62,900 doctors by 2015.(6) Inspite of the crushing debt imposed on graduating medical students and the delayed earning power resulting from an additional 3 to 5 years of residency training after medical school graduation, tons of kids still want to go to medical school. This helps explain, in part, why 16 new medical schools have opened in the past decade with another 12 in development.(6) To do what? To largely train kids how to practice medicine the way it has always been practiced – rather then as it soon will be practiced.
So will health care demand exceed physician supply? Well that depends on what kind of delivery system we develop, what we expect these new physicians to do, and how well trained they are to do it efficiently. It also depends on how many other clinicians like Patricia Dennehy are helping care for all these people.
Dr. Bill Frist recently said, “To meet the explosive demand of primary health services will require a truly disruptive reform of how primary care is delivered. Delivering primary care will not remain the sole purview of doctors. There are not enough of them, and they are too expensive. Expanding the scope of practice of Physicians Assistants and advanced practice nurses simply has to occur.”(6)
Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, tied this expansion (supported by a recent Institute of Medicine panel) back to training with this commentary: “…This creates an imperative for academic medical centers to respond with new approaches to training, as well as research regarding which educational and care models work best.”(6)
Money is tight. The health sector is out-of-date. Job descriptions haven’t been fundamentally updated in a century.
Do we need more doctors? Maybe not. In the long run, we may be better off holding tight and using all the human resources we have to maximum benefit.
For Health Commentary, I’m Mike Magee.
1. Magee M. Will nurse practitioners fill the primary care gap? http://www.healthcommentary.org/?p=4877
2. Dennehy P. Healthcare Reform’s Missing Link – Nurse Practitioners. Los Angeles Times. February 22, 2012.http://thehealthcareblog.com/blog/2012/09/08/healthcare-reforms-missing-link-—-nurse-practitio/
3. Affordable Care Act – Implementation Timeline. The White House. http://www.whitehouse.gov/healthreform/timeline
4. IOM: The Future of Nursing – Leading Change, Advancing Health. October 5, 2010. http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
5. Snyderman R, Yoediono Z. Perspective: Prospective health care and the role of academic medicine: lead, follow, or get out of the way. http://www.ncbi.nlm.nih.gov/pubmed/18667879
6. Iglehart JK. The Uncertain Future of Medicare and Graduate Medical Education. http://www.nejm.org/doi/full/10.1056/NEJMhpr1107519
7. Association of American Medical Colleges. Physician shortages to worsen without increases in residency training https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf