Politics & Economics of non-physicain primary-care practitioners (NPs, CNMs LMs) ~ part 1

by faithgibson on February 22, 2013

in AB1308, new regs & new legislative efforts, Physician Supervision Issues

The following is background information on the politics of multi-disciplinary healthcare that includes the independent practice of nurse practitioners, CNMs and LMs. It is an excerpt from a much longer essay that explores why our current healthcare system:

  • Doesn’t work for so many of us . . . answer:  because what we have now is a very expensive but ultimately ineffective ‘sickness-care’ system
  • Isn’t sustainable . . . answer:  because a ‘sickness-care’ system is too expensive to maintain without millions of uninsured, quotas for care and ultimately, some form of ‘death panels’
  • Why America but not other comparable countries has entrenched such a dysfunctional system . . .answer:  the AMA‘s successful strategy via the Flexner Report in 1910 to eliminate multi-disciplinary HEALTH care and replace it with “chokepoint medicine” — MD-centric, allopathic-only medical care that about managing people after they become sick
  • Why chokepoint medicine doesn’t serve us:answer: because it chokes up the point of entry into the health system by making everyone be seen first by doctor BEFORE they can get access to non-physician primary-care services (nurse-practitioners or professional midwives)
  • What to do to repair the damage and fix the problems: answer: replace chokepoint medicine with a truly multi-discipline healthcare system that includes the independent practice of non-physician primary care practitioners as a normal part of its mainstream services

The Numbers ~ Everyday Non-urgent Health Care: 

Approximately 90% of all medical appointments are for non-acute healthcare needs. This category includes “self-limiting conditions” i.e., temporary situations that resolve spontaneously. By definition, self-limiting conditions do not need or benefit from sophisticated medical technology, prescription drugs or surgery.

The illustration often used is that a cold, if untreated, will go away in seven days; if treated, it will go away in one week. Ordinary, garden-variety complaints include mild illness or minor injury, psychological states such as anxiety or mild depression, normal biological conditions such as pregnancy, breastfeeding, newborn follow-up, well-woman care (contraception, pap smear), normal aspects of aging, life-style issues (diet, exercise and questions about sexual topics), school and work physicals, vaccinations, testing for STDs, managing a stable chronic disease, etc.

Challenging Chokepoint Medicine:

In the early 1900s, primary care was provided by a mixture of MDs, non-allopathic physicians (osteopathic, naturopathic and eclectic doctors) and non-physician practitioners (including midwives). In 1910 organized medicine chose to do away with the traditional multi-discipline form of health care and replace it with an exclusively allopathic one.

The decision to get rid of non-allopathic physicians and non-physician practitioners occurred without any prior scientific research and without making any distinction between ambulatory care — non-urgent care for everyday self-limiting health-related conditions — and urgent medical intervention for serious and acute medical problems. Nonetheless, it was widely assumed by the medical profession, as well as many members of the public and all the state legislatures, that the allopathic model of medical care was the only scientific method and it represented 100% of what we now call “modern medical care.

Chokepoint Medicine is born

As the one and only way to to provide health-related care,  medical doctors believed and the state legislatures passed laws that “modern medicine” as a model built about a chokepoint. This specific configuration meant that every non-urgent patient must first go thru the eye of a needle to see and be seen by a medical doctor before any other aspect of the health care system can be accessed.

The big question is whether 9 to 13 years of extremely expensive medical school training in life-threatening medical emergencies and the use of prescription drugs and surgery is actually the most appropriate way to provide safe and cost-effective for every headache, earache, sniffles, sore throat, tummy ache, backache, athletes’ foot, trouble sleeping, normal pregnancy, healthy child check-up and all the other non-urgent and self-limiting conditions that fill up a physician’s waiting room every day?

Can this possibly be rewarding way for a highly-trained medical doctor to spend his (or her) time?

Time vs. Money:

These health-related concerns are not medically complicated, but can be time-consuming and certainly take more than the 6 to 10 minutes allotted for the typical non-urgent medical or OB appointment.

What people seeking non-urgent health care want and need is a relationship with an unhurried primary-care practitioner who is able and willing to be empathetically present, to listen, talk, ask questions, sympathize, make suggestions, and spend whatever time it takes to educate the patient (or parents) about how best to manage their health.

Let me emphasis the above list of verbs in relation to their most common, most vital element — unhurried TIME to be present:

…. to listen, to talk, to ask questions, to sympathize, to reassure, make suggestions and spend whatever time it takes to educate the patient (or parents) about how best to manage their health …

Not enough of both to go around:

By 2025 the growing US population, which includes children and increased proportion of elderly people, is expected to raise the number of ambulatory care visits by 42%. That means the 900 million visits to clinics and doctor’s offices in 2009 will rise to 13.5 million.

The number of patients with chronic diseases – a category who benefit most from the coordination and continuity of care of NPP — is also increasing. [Am Coll Physicians – White Pager 2008].

By reducing rate of obesity, diabetes, osteoporosis and many other chronic and expensive diseases thru high-quality primary care, it eliminates the great volume of expensive and invasive procedures currently driving up the cost of health-related services, most especially in regard to Medicare and Medicaid populations.

Institutionalized Mismatch:

According to Dr. Atul Grover, chief lobbyist for the Association of American Medical Colleges (an arm of the AMA), the answer is a 30% increase in medical school enrollments, in order to produce 5,000 additional new doctors each year in perpetuity.

However, this still misses the point, which is the extreme mismatch between what patients need and want from primary care providers, what society needs from medical doctors and what physicians themselves need and want from the practice of medicine.

From a patient’s perspective, it must be nearly impossible to get cost-effective services for routine low-tech care from a physician who is trying to pay off an average of $140,000 in med school loans AND simultaneously meet staff payroll, office overhead and malpractice insurance premiums. There is already one MD for every 373 people in the US. The number of doctors who report quitting their primary practice because they couldn’t make enough money to stay in business is eye-opening and distressing – the economics of primary practice by MDs does NOT work.

Un-choked, unhurried primary care:

Time and relationship-intensive non-urgent care is most satisfactorily provided by non-physician primary care practitioners – physician assistants, nurse practitioners, professional midwives, naturopaths, etc. This is where preventative medicine actually starts. It is also how the routine overuse of Rx drugs and medical and surgical procedures is stopped.

A consensus of the scientific literature identifies primary health care by independently practicing non-physician practitioners to be comparatively safe, more cost-effective than MD care and to have a high patient-satisfaction rating. Currently there are about 140,000 non-physician practitioners practicing in the US (not counting non-nurse midwives). In event of a serious or urgent medical situation or request by the patient, non-physician primary care practitioners arrange for referral, consultation or a transfer of care to an MD or emergency facility.

Concurrent Reform in Medical Education:

Incorporating non-physician practitioners into a health care must includes change in the way all we educate MDs and non-physician primary care practitioners. We need a broad-based multi-disciplinary approach, instead of the current system that teaches students of each health care discipline in total isolation from every other healthcare discipline. In the current system, students of medicine, nursing, midwifery, physician associates, naturopathy, etc never even met each other during their training.

At the most basic level, the body of scientific knowledge for bio-medicine includes the same course work for all primary care providers – anatomy, physiology, microbiology, taking and interpreting patient history, the logical steps of systems review and physical examination and fundamental treatment of minor problems and self-limiting conditions.

If all medical students and all non-physician practitioners (students of nursing, midwifery, physician assistants, etc) sat in chairs next to each other in same room, studied the same curriculum, learned from the same teacher at the same time, it would have two every important contributions to the health care system.

First, it would teach every physician-to-be how to function as a primary care provider before exposing them to the more complex world of specialty medicine. For instance, med students would learn how to mange normal childbirth using the principles of physiological management before learning the standard obstetrical intervention of medically managed childbirth.

Secondly it would forge collegial bonds between these different disciplines of health care providers that will last a lifetime. The result would be a cooperative and complimentary professional relationship between those students who continue on to become MDs and those that have chosen to become non-physician practitioners.

Without this change in how we think about primary care and how we train physician and non-physician practitioners who provide primary care, we will stay stuck in the same 19th century thinking that has distorted the entire health care system for a century and continues to systematically (structurally) block the self-correction of these problems.

Continue to part II: Non-physician primary care providers a threat to Organized Medicine (OM): 

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