On Wednesday, I wrote about “scope of practice” – what health care providers, particularly nurse practitioners, who aren’t physicians are or are not allowed to do in their state. I provided several resources, reports and links to understand these fights, and the role nurses or physician assistants or other providers can have in providing primary care in underserved areas. Today I want to look at two stories:
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.
The first was published earlier this fall online by Tina Rosenberg on The New York Times Opinionator section, part of a series called “Fixes” on solutions to social problems . She profiles a clinic in Indiana that provides full-service health care to 10,000 people – without any doctors. It’s one of about 250 clinics in the country run by nurse practitioners. Rosenberg reviews the reasons that there aren’t enough primary care doctors serving the poor or practicing in rural areas. She writes:
It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.
She says nurses are trained to do what many doctors do not learn – how to treat a patient more holistically, how to listen, how to “coach more, and lecture less.” All those skills are part of what’s needed to treat and manage chronic disease – which is what so much of primary care is about. Because nurses at the clinic are salaried, they aren’t stuck in the 15-minute-appointment hamster wheel of fee-for-service medicine. “At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.”
She looks at the economics – nurse-run clinics are usually, but not always, cheaper than physician-run counterparts. These clinics also keep patients out of the emergency department. But most states have scope-of-practice laws that limit the role of nurses. (In Indiana the restrictions are a bit strange – a nurse practitioner can do everything a physician can do except prescribe physical therapy or do the physicals for high school sports).
The second piece is from AHCJ member Christine Vestal, at Pew’s Stateline, and it looked at a similar clinic, in a logging area in rural Virginia. The clinic, which treats 200 people a day, is the only source of medical care around. This one, though, has four doctors and two nurse practitioners “who provide the same care, to the same number of patients.”
Vestal describes some of the larger national conflict:
Organized physician groups, which hold sway in most legislatures, are reluctant to cede professional turf to nurses. Arguing that nurse practitioners lack the necessary level of medical training, they insist that it is unsafe for patients to be treated by nurse practitioners without a doctor’s supervision.
Some doctors also have a financial incentive to limit nurses’ independence. Often carrying heavy medical school loan debt, they can be loath to see their revenue diverted by competing health care services, particularly those with lower fees. The Federal Trade Commission has weighed in on legislative efforts to give nurse practitioners more autonomy in several states, arguing that physician groups have no valid reason for blocking such laws other than to thwart their competition.
Virginia loosened its rules a few years ago. Doctors still have to supervise the nurse practitioners but they can do it remotely, and the number of nurse practitioners who can practice per supervising physician rose from four to six. Still there are conflicts, and new rules are being finalized to address them.
One point of contention; the provision that requires the nurse practitioner to consult the supervising physician about “complex” cases. At the clinic Vestal wrote about, it’s not a problem. The nurses and doctors work together all the time. But then she wrote about another pair of nurses, Teresa Gardner and Paula Mead, who provide care through a mobile “Health Wagon” that they take throughout a very poor part of Virginia near Tennessee and Kentucky. They have a physician, Joseph Smiddy, who supervises them on a volunteer basis from his own practice. But in the four counties they serve, where the coal mines are idle, the people are poor, and COPD, heart disease, mental illness, prescription drug abuse, obesity, diabetes and cancer are rampant, and just about every patient is “complex.”
“Dr. Smiddy would murder me if I called him every time a complex case walked through the door,” Gardner told Vestal. “They’re all complex. Most of them are train wrecks. I’d love to treat someone with a common cold.”
