April 6, 2010
Who Will Be Your Health Care Provider?By David S. Van Dyke
Although the dust is still settling since the passage of ObamaCare, it's not too early to start thinking about who will be providing your health care a few years from now. More specifically, who will be the practitioners who actually provide your health care services?
A recent AT article described the difficulty associated with training a physician. Similar difficulties exist for the training of dentists, pharmacists, nurses, and other health care professionals. Physicians may be at the top of the medical food chain, but they don't function in a vacuum. Health care is incredibly complex, and the various disciplines and sub-disciplines are inextricably interconnected. As demand for physician services increases, the demand for the services of all associated health care practitioners increases accordingly.
The recently passed health care legislation will, among other things, expand the rolls of Medicaid by 16 million eligible recipients and force another 15 million without health insurance to purchase health insurance. This will undoubtedly increase demand for the services provided by physicians, dentists, nurses, pharmacists, and other professionals. There are currently shortages of physicians, dentists, nurses, and pharmacists in most states. How do we address a shortage exacerbated by dumping tens of millions of newly entitled patients into the system? One might be tempted to look at the associated federalization of student loans and suggest that we should simply decree that more physicians, dentists, nurses, and pharmacists shall be trained to meet this demand. Voilà! Problem solved.
Unfortunately, this is not as easy as printing money. Health professionals are more like gold: You must mine them and refine them. One of the critical rate-limiting steps in training health care professionals is the availability clinical training sites. In the late 1990s, all accredited schools of pharmacy decided that the entry-level degree for the practice of pharmacy would be the Doctor of Pharmacy degree (Pharm.D.) by the year 2000. The Pharm.D. degree had existed for decades, but it was generally a post-graduate degree earned by those who specialized in the practice of clinical pharmacy. Many schools never offered a doctoral curriculum, some were only just starting one, and some had transitioned to an all-Pharm.D. curriculum years ago. The result was that many schools found it very difficult to find an adequate number of clinical instructors and training sites to meet the mandates for experiential training.
Virtually all pharmacists who graduated after 2000 are "Doctors of Pharmacy." This additional training may be a net benefit to your typical retail pharmacy, but the rigor of the old post-grad, clinically focused Pharm.D. programs had to be watered down to get an entire class through. To meet the demands of hospital-based clinical pharmacy services, the number of post-grad residency programs increased.
Did these Pharm D. requirements do any good? Not really. Pharmacy schools got richer because they kept students in school longer. Those who earned the older, more scholastically and experientially demanding Pharm.D. degree saw their academic credentials cheapened. Younger pharmacists paid much more for their education. Pharmacists' salaries increased markedly -- not because of the new entry level degree, but because of a scarcity of licensed pharmacists. In most cases, the degree (B.S.Pha. vs. Pharm.D.) makes little difference in the salary a pharmacist earns; years of experience have a much greater influence. The license to practice is the most valuable commodity.
It is virtually impossible for government to approach medical schools with a big pile of money and tell them to increase their output of (the same quality) physicians by 20% in the next five years. This is not to say that the schools wouldn't agree and take the money -- they almost certainly would. The problem is that they wouldn't succeed. Academia is, after all, a business. Money can't buy all the resources necessary for training professionals. Their entry requirements would be relaxed, the didactic requirements would be diluted, and their experiential training sites would be stretched to the breaking point. The result would be a graduate with less training. Then the schools would have to consider the increased demand for additional residency slots (these are not developed or funded quickly). One can extrapolate this problem to the training of dentists, pharmacists, nurses, or any other health professionals. So what do we do?
The first and most obvious solution would probably be to import more health care professionals from other countries. Foreign medical graduates (FMG) are required to go through testing to assure that they meet minimum requirements for licensure in the United States. One has to consider that every physician or nurse trained in another country and working in the U.S. is one less physician or nurse practicing in his or her native country. Is this moral? Many FMGs have taken residencies in the U.S. and have gone on to become excellent practitioners. At the same time, many will always remain on the left-hand side of the competence bell curve. Although the U.K. is aggressively employing the importing option to meet their needs for medical professionals, it is ultimately unsustainable. But there are other options.
There is no acceptable substitute for the skill of a well-trained surgeon or the diagnostic acumen of a board-certified internist. A dental hygienist or assistant cannot perform the same procedures as a dentist (essentially a very specialized surgeon) can. A nurse assistant does not possess the same clinical judgment as a nurse. A pharmacy technician cannot make the same professional and clinical decisions as a pharmacist.
There are, however, workable solutions to allow these professionals to practice more efficiently. Dentists employ hygienists and assistants that allow them to treat more patients than they possibly could if they performed all the tasks themselves. Nurses (at least in hospital and clinic environments) have assistants to perform routine tasks so that they may serve more patients. In most cases, pharmacists have (often registered) pharmacy technicians making computer entries and preparing prescriptions so that they can devote more time and attention to evaluation of treatment and patient counseling. Many physicians employ physician assistants to see patients for routine checkups and management of treatment. Some states go even farther in allowing such assistants to treat patients.
Another solution to our impending predicament would be to expand utilization of "midlevel practitioners." Midlevel practitioners include Physician Assistants (P.A.), Nurse Practitioners (N.P.), optometrists (O.D.) trained and certified to prescribe, clinical psychologists (Ph.D. or Psy.D.) trained and certified to prescribe, and clinical pharmacists licensed to prescribe. The extent to which any of these practitioners may practice, and the conditions under which they may practice, vary widely from state to state and usually constitute a politically contentious issue.
New Mexico licenses all the midlevel practitioners listed above. A Physician Assistant has prescriptive authority but ostensibly practices under the direct supervision of a physician. In practice, this is laughable, as the physician isn't even necessarily on-site when the patient is seen. The supervising physician is required to review the charts of the P.A. after the fact and sign off on them. Nurse Practitioners are essentially R.N.s with a master's degree and specialized training. They have independent practice and prescriptive authority in NM. They can legally hang out a shingle and go into independent practice (and many do). The optometrists have prescriptive authority limited to their scope of practice (e.g., dilate pupils, treat glaucoma, eye infections, and "chronic dry eye").
This is also the case with clinical psychologists. Their prescriptive authority is limited to their narrow scope of practice. Usually this is limited to the treatment of ADHD, depression, and anxiety. Most cases of profound schizophrenia are generally referred to psychiatrists.
The pharmacists (pharmacist clinicians or Ph.C.) receive an additional year of training. Their prescriptive authority is the same as that of P.A.s. It is specifically and narrowly defined by protocol and must be "supervised" by a physician. Some serve in the role of primary care providers, but most specialize in managing anticoagulation in warfarin clinics. Their utility in community health clinics is limited because of their prescriptive authority. A clinic can hire two P.A.s for the salary of a single pharmacist. There are both advantages and disadvantages with all of these practice types.
The problem is defining what a midlevel practitioner can and should be allowed to do and what only a physician should be allowed to do. A tremendous number of physician office visits (and even E.R. visits) could be shifted to midlevel practitioners. Many chronic disease states require periodic monitoring and perhaps adjustment to the prescribed medication regimen. This does not require the attention of a physician each and every time. Many minor, acute situations do not necessarily require physician evaluation. At the same time, physicians sometimes make other diagnoses when patients show up for routine visits.
The opportunity for significant savings and increased patient accessibility to health care providers exists only if the roles for midlevel practitioners are expanded and more clearly defined. The problem is that there are fifty states with multiple regulatory boards that will fight these changes tooth and nail. In the end, it might not matter. If the need becomes acute enough, the changes may be willed into being by legislative fiat.
The fact is that we as a nation can neither produce nor import enough medical professionals to meet the demands soon to be placed on our medical system. Many physicians will choose to retire, and fewer of the best and brightest will choose to enter the field. All the while, more and more demands will be placed on all health care professionals. In the end, something's got to give. Unless this is stopped, in five years' time, "health care" will be delivered by a whole new group of practitioners. In many cases, it may be "adequate"...and in many other cases, it may not.