Has Anyone Asked the Patient?

Most Americans are increasingly aware that the Patient Protection and Affordable Care Act (PPACA, a.k.a. ObamaCare), is actually making patients less protected (losing their coverage), and is rendering health care less affordable (through rising premiums). The stories about UPS (15,000 spouses cut from employee's plans), Forever 21 (all non-managers' hours cut to below 30 per week), the latest Kaiser Family Foundation survey (average premiums up $3000 since 2009) and more, are daily and incessant reminders that something is terribly wrong.

But what people may be less aware of is the subtle shift in what the very terms 'health care' and 'coverage' are coming to mean under the new regime. In particular, Scope of Practice Expansion and 'provider non-discrimination' are twin movements to have nurse practitioners, pharmacists, physical therapists, chiropractors, optometrists and other non-physicians legally licensed to do more of the work that has commonly been limited in the past to fully licensed physicians. For example, nurse practitioners are becoming licensed to set up independent medical practices (independent meaning without the supervision of a physician), sign death certificates, prescribe drugs, and act as primary care providers, with many of the privileges that have traditionally been reserved for physicians.

These changes in law and regulation have been and continue to be actively lobbied for by groups like the American Physical Therapy Association, the American Optometric Association, the American Chiropractic Association, the American Academy of Nurse Practitioners and several other groups collaborating under the umbrella of the Patient's Access to Responsible Care Alliance (PARCA). They have the support of academics in places like the Harvard business and medical schools and the Innosight Institute. Policy makers see in scope of practice expansion and 'minute clinics' operated by nurse practitioners, a solution -- or at least a pressure escape valve -- to the increasingly acute physician shortage and perceived high cost of physicians' services.

But is this what patients want?

Provider nondiscrimination may be perceived as a positive victory for liberty and the free market. But are patients even aware that this campaign is going on in our state legislatures, and that it will affect the care they personally receive today or in the future? And most importantly, if they don't want it, will they have a choice, once the force of law and the regulations are behind it? Patients already have severely limited command of the resources spent on their behalf. It's not liberty or free-market if the citizen/consumer has no say.

Most patients, when given a choice, would prefer to see someone with 7 years of post-baccalaureate education and 22,000 hours of clinical training over someone having only 2-3 years and 5,400 hours. People with serious health concerns want the best doctors in the world on their case, preferably before some well-meaning but less qualified caregiver prescribes some treatment that does more harm than good. Will these patients have that choice under ObamaCare and mandated scope of practice expansion?

Section 2706 of the PPACA, also known as the Harkin Amendment, forbids insurance companies from discriminating against any health care provider who wants to participate in a plan if they are licensed to perform certain procedures. Superficially this appears harmless; if a person is licensed by their state to do something, why should he or she be prevented from doing it? But having one party permitted to perform some service and having the other party obliged to receive that service are two different things. Regardless of whether or not a provider is licensed to perform a medical procedure, an insurance company or individual or group of patients might wish to establish higher standards. For example, even though some nurses are licensed to administer general anesthesia in surgery, a patient and/or an insurer and/or the surgeon (who is ultimately responsible for the patient's life) might prefer a fully licensed physician anesthesiologist, especially in higher-risk cases. This law denies that free choice option to the insurer, and by extension, to the patient.

Physicians have been depicted by some politicians as rich, greedy one-percenters who would rather saw your leg off than give you an aspirin. The American Society of Anesthesiologists, the American Medical Association, the American Academy of Ophthalmology and the American Osteopathic Association are easily portrayed by political opponents as nakedly self-serving special interests protecting their turf. On the other hand, who else is qualified to raise the issue of patient safety? Politicians? Medical personnel with less education, training, and expertise?

The reason we don't have a pure libertarian policy in health care, where anyone may do anything whatsoever to a consenting adult, that is, the purpose of licensing laws and boards, is patient safety. We have collectively deemed it too dangerous to permit a free-for-all market in medicine without sufficient safeguards against well-meaning but insufficiently qualified practitioners, to say nothing of quacks and charlatans; we require evidence of training, experience and expertise in specific disciplines by recognized institutions. But the legislators and politicians to whom we delegate the authority to confer certificates of licensure are not qualified to judge professional medical standards. The logical and necessary consequence of licensure is that those to whom we confer the highest honor by virtue of expertise and merit, must have authority over others in the governance of professional practice.

Or at the very least, we might listen to what they have to say about patient safety, and why they stand opposed to scope of practice expansion.

By all means, let's promote the civil rights of non-physician practitioners, let a thousand flowers bloom and put a wider range of options on the table. But while we are doing so, let us address the hostile regulatory environment that is chasing physicians out of business, out of private practice, herding them into employee roles at large hospital corporations and ACOs or out of medicine altogether, and let's ensure that the patients and their families are the first to be served.

Barack Obama famously promised, while selling his signature health care reform bill, that "If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you'll be able to keep your health care plan, period. No one will take it away, no matter what." On the very next day he began the hemming and hawing that continues to this day to 'clarify' those promises. Today the truth might read more like "If you like your doctor, we will have nurse practitioners, physical therapists and naturopaths do more of the procedures that your doctor used to do, so you'll have even more of a good thing (whether you like that idea or not). If you like health care, we'll give you something of our choosing and call it health care. But in any case, no one will repeal the PPACA, no matter what."