April 29, 2013
The P-E's coverage of the conflict between medical providers over state legislative proposals that would expand scope of practice for non-physicians ("Medical school money in health care turf war mix," April 19) concisely summarized concerns surrounding the soon-to-explode numbers of people who will need care under the Affordable Care Act (ACA).
Chief among these is that while there aren't enough primary care physicians to meet the expected demand, physician groups are aggressively opposed to expanding scope of practice regulations for optometrists, nurses, and pharmacists so that they could perform some basic primary care functions and help address the growing need in that area. Their argument is that what's needed are more doctors, and thus more medical schools like the one planned at UCR - not expanded roles for non-physicians.
But solving the challenge posed by the increased need for primary care is not this cut and dried. It is not an either/or situation, where one side "wins." This notion of a "turf war" between interest groups ignores the most important person of all, the one in whom every health care provider should be most interested - the patient. How do we best address their health issues? How do we ensure they receive the care they need in a timely fashion? How do we make them aware of all the medical resources available to them in the brave new world created by the ACA?
The myriad care and accessibility problems created by the Act - problems resulting from a noble cause, to be sure - cannot be solved by the current system, and require a multi-disciplinary approach. Here's why:
- The need is now. The ACA's provisions take full effect in 2014. Even if several new medical schools are up and running within the next few years (which is unlikely), or existing medical schools drastically expand enrollment, they will not have their first graduates until 2018-2020 at the earliest, and those graduates must then perform residencies - assuming they can find them (Graduate Medical Education slots have not increased for 16 years). The best-case scenario makes this first wave of "new generation" physicians available to meet ACA demands in 2020 - six years after the law takes effect.
- The numbers don't add up. Medical schools alone simply cannot produce enough graduates to meet anticipated primary care demands. They already can't keep pace. According to sources as diverse as the U.S. Senate Subcommittee on Primary Health and Aging and the Association of American Medical Colleges, the current physician shortage ranges from 13,000 to 17,000, and is expected to grow to 125,000 to 160,000 by 2025. The U.S. currently has 141 osteopathic and allopathic medical schools. If each one graduated 100 additional students right this minute, the nation would barely cover the current minimum estimated shortage. What's more, even with 2025 as a target, each of those schools would need to graduate 887 additional students over the next 12 years, requiring the addition at each school of 74 students per year above and beyond what they already enroll. That might not sound like a large number, but when one considers the expense and time involved in training a physician, not to mention the expansion of physical resources that would be required; it's a huge commitment - one that would be impossible for most schools to make.
- Other health disciplines are qualified. Especially for the types of basic primary care described in California's proposed scope-of-practice legislation, health providers outside of MDs and DOs are abundantly qualified. Dentists, optometrists, pharmacists, nurse practitioners, physician assistants, physical therapists ... all are taught and become expert at levels of care they aren't even allowed to practice under existing law. Many are among the most finely trained - yet drastically underutilized - health professionals one will find anywhere. For example, just 18 states allow nurse practitioners to see patients without a referral from a physician, despite their qualifications in wide range of primary care services. Pharmacists, who are educated to address a panoply of health issues and conditions, perform physical assessments, order and interpret lab tests and offer follow-up care - but only if they work for the federal government, which allows pharmacists to use their qualifications to their fullest extent. Private-sector pharmacists, with a few exceptions, are not allowed to offer these services, yet have the same level of training as their federal counterparts.
The list goes on. Dentists, optometrists, physical therapists, physician assistants ... all are capable of offering more expert care than they are allowed.
Health professions universities across the country have for many years recognized the importance of a team-based approach to patient care, with some - including WesternU - going so far as to develop special courses of study (interprofessional education) to emphasize this new paradigm. The effort behind such initiatives is driven by the recognition that most health-sciences disciplines teach a broad array of skills that - despite being drastically underutilized in the current care environment - could go a long way toward distributing the burden for many primary care services across several fields, rather than having it fall solely on the shoulders of already overtaxed primary care physicians. This has the added benefit of fully integrating all members of a health care team toward a single goal - better health for the patient.
Today's health-sciences graduates could do a lot to address the current and looming primary care shortage in our country - if only they were allowed to do so. The nearly 1,100 pieces of scope-of-practice legislation working their way through state legislatures across the country, including several in California, are testament to the fact that the traditional methods of administering primary care services can't continue if demand is to be met.
Now is the time to adopt a truly team-based approach to health care, and to help those most in need of these services - patients - by working collaboratively not only to graduate more physicians, but to expand scope of practice in other health-care disciplines.