Will More Doctors Solve the Health Care Crisis?

On May 15, 2009, after President Obama’s “stakeholder” meeting at the White House I wrote a post called Consumers are the Ultimate Stakeholder in Health Care Reform. But consumers were not invited to the White House – neither were nurse practitioners.

Shortly after that White House meeting pundits from the Innosight Institute who are also authors of a book The Innovator’s Prescription: A Disruptive Solution for Health Care published a commentary piece on CNN Politics.com titled We Don’t Need More Doctors. These scholars have some great ideas that might work – but some need a little fine tuning. Overall their perspective is very refreshing!

Meet the Pundits

Clayton M. Christensen is the Robert and Jane Cizik Professor of Business Administration at Harvard Business School, co-founder of Innosight Institute, and the best-selling author of six books. Jason Hwang, M.D., M.B.A. is co-founder and executive director of healthcare at Innosight Institute. They are co-authors of “The Innovator’s Prescription: A Disruptive Solution for Health Care” (McGraw-Hill, January 2009). Vineeta Vijayaraghavan, M.B.A. is a Research Fellow at Innosight Institute.

Is Reform Going to Be Real or Just “More of the Same”?

The Association of American Medical Colleges advocates a 30 percent increase in medical school enrollment to produce 5,000 more doctors a year. While at first glance that may seem like a cure to the problem of too many patients for too few primary care providers, these pundits (among others) make the point that it is not the number of doctors but how they are distributed that counts.

The White House proposes redistributing payments from specialists to primary care doctors to improve pay equity – i.e. robbing Peter to pay Paul – but these pundits suggest that these actions lead in the wrong direction, and there is in fact, no doctor shortage at all.

They propose that we accept that it is actually possible for health care to work differently, and better, than the current system. They acknowledge there IS a shortage of health care services being provided, but many of the services needed are not best offered by a doctor.

My Note: I could not agree more. You do not need to be Chief of Staff of Harvard Medical School to manage most of the common health problems that need medical management in today’s system. In fact, most of them are lifestyle diseases that can be managed much better by nurse practitioners than physicians. This will free up physicians to care for more higher acuity cases.

Solutions the Pundits Propose

NP Run Retail Clinics. “A child has an ear infection, treatment involves considerable pleading for a standby appointment at the doctor’s office, followed by a long wait, a 30-second visit with the doctor, and then a trip to the pharmacy for another long wait. Many common problems and chronic diseases could be better handled in nurse [practitioner] run clinics.”

“Retail clinics record average patient satisfaction scores of 4.9 out of 5, while providing care that is 32 to 47 percent below the cost of primary care physicians. While the rest of the health care system only delivers about 55 percent of recommended care, MinuteClinic staff demonstrated 99.15 percent adherence to clinical guidelines in a study involving over 50,000 visits.”

My Note:: This is compelling. I do have to offer the following perspective on this statement from their commentary:

“incorporating quick and easily interpreted diagnostic tests and algorithm-driven care for conditions such as ear infections, sore throats and minor burns, can be handled better in nurse-run clinics.

1. These are not nurse run clinics, they are nurse practitioner run clinics. This is an important distinction. If we are going to lay out new health care policy, let’s learn who the players are and use language to describe them more precisely, please.
2. Retail run clinics are successful because they are convenient, have a high level of customer satisfaction and because they follow evidence based practice (i.e. good medical practice). Statements like “quick and easily interpreted diagnostic tests and algorithm-driven care” imply that NPs are somehow practicing paint-by-number medicine and this is not the case. Medicine can not be practiced successfully without good judgement and NPs have proven themselves to be thoughtful diagnosticians and practitioners for more than 40 years in a wide variety of settings. Retail clinics have just gotten the most press.

Empower primary care doctors to do more. There will always be “thorny medical problems for which we need physician care”. However, robbing Peter (the specialists) to pay Paul (the primary care physicians) will “only further diminish access to complex care”. Instead, “employing expert systems software to guide generalists through the same decision-making steps that a specialist would take would allow for diagnoses to be made promptly in the clinic”

“These innovations deliver convenience to patients, eliminate the need for referrals to costlier specialists, and improve job satisfaction by enabling primary care doctors to deliver increasingly sophisticated care. Moving more complex care from specialists to primary care providers, the payments will follow. These changes would make primary care more fulfilling and financially rewarding, while freeing up specialists to do even more complicated work that merits their additional training.”

My Note: I’ll be interested to see how the docs take to this idea. I think it does make sense to distinguish patients who need routine and preventive medical care from those that require more specialized care. Nurse practitioner practice (which is 80% of a primary care physician’s) are well trained to handle a significant portion of routine primary care. Patients with problems beyond NPs’ scope should be seen by a physician generalist. Those who require care beyond the scope of a physician generalist should be seen by a specialist.

In primary care there is a lot of overlap between NP practice and phyician practice. Organized medicine’s continued insistance on maintaining supervisory control over NP practice (in spite of a multitude of studies that prove NP practice is both safe and effective) results in a lot of wasted time and duplication of services. This could be eliminated if every health provider were free to practice to the full extent of their experience and expertise. If primary care physicians would acknowlege NPs as qualified and independent primary care providers in their own right and exchange referrals with NPs the same way they do with specialists that would add 125,000 primary care providers to the system instantly.

Overcoming the Maldistribution of Providers

One cause for the shortage of doctors is that they are unevenly distributed around the nation. Inner cities and rural communities are struggling the most.

The pundits recommend “embracing eHealth initiatives and technologies that enable virtual clinic visits and online house calls. Offering such convenient and affordable channels to primary and preventive care is vital to relieving our overburdened emergency departments and public health system.”

My Note: What people need and want most is care and caring. Care is an essential ingredient in healing. It can not be effectively delivered when either the recipient or the caregiver is overburdened. I bet face to face NP case management would succeed better than online house calls by harried docs – but let’s try it all and see what works best.

How Do We Define “Quality Care”

The pundits point out that the “definition of quality care in the past has assumed that more expertise is always preferred — doctors must be better than nurses, specialists must be better than primary care doctors, and brick-and-mortar must be better than a virtual interaction.”

My Note: Maverick Health was founded on the proposition that this hierarchy is false and counterproductive. Maverick Health defines quality care as patients’ having access to high quality information that promotes optimum self-care plus the right to seek and receive care from their health professional of choice at any given point in time. Sometimes that will be a doctor and sometimes a nurse practitioner.

The pundits write “patients want correct diagnoses and effective therapies, but they also value accessibility, convenience, transparency, communication and their time and money — none of which have been priorities of the traditional health care model.” [See my post Consumers are the Ultimate Stakeholder in Health Care Reform.]

Will More Doctors Solve the Health Care Crisis?

According to the pundits “rather than calling for more doctors, what the country really needs are policies that pave the way to more avenues of care.”

My Note: Nurse practtitioners are an avenue of care which have no proven downside. Thus far, though, our effectiveness is restrained by legislative practice and prescriptive restrictions that prevent us from practicing independently and innovating freely.

P.S. It is incorrect to use the words “nurse” and “nurse practitioner” interchangably. Please see my post It Is a Mistake to Call a Nurse Practitioner a Nurse.

This information is offered for educational purposes only and is not intended to diagnose, prescribe or treat. For that please seek direct care from a health professional.

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