OP-ED

Physicians, Nurses and the Coming Transformation of our Health System

Last week, we highlighted an unintended consequence of the Affordable Care Act: it will dramatically worsen an already gaping mismatch between the demand for and the supply of physician services in the US. Put simply, there aren’t enough white coats out there to care for 32 million Americans who will obtain health insurance coverage for the first time as a result of the new law. It’s not even close.

We also speculated that the recommendations made by the American Association of Medical Colleges to address the burgeoning crisis will not work. The AAMC wants Congress to increase the number of Medicare-funded medical residency training slots—essentially, to increase the pipeline for new physicians. This isn’t a bad idea except that Congress is gridlocked on a good day, bitterly divided on all things health reform, and in no mood to enact spending programs of any sort.

That brings us to an alternative solution, proposed recently by the Institute of Medicine. In a report titled, The Future of Nursing: Leading Change, Advancing Health, the IOM concluded that the best way to meet the coming tidal wave of demand for medical services is through a sweeping expansion in the roles and responsibilities of nurses.

Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended the implementation of incentive programs which would assure that 80% of nurses have a bachelor’s degree within 10 years, and that 10% of such nurses enter advanced degree programs. It recommended further that nurses should assume central roles in redesigned, team-based care systems, and that regulatory and institutional obstacles, including limits on nurses’ scope of practice, should be removed so that advanced practice registered nurses (APRNs, including nurse practitioners) can practice more freely. This includes increasing their power to prescribe drugs.

To support its recommendations, the IOM cited studies describing the experiences of health care organizations that already have expanded the roles and responsibilities of nurses in patient care. The studies show that nursing professionals deliver safe, high-quality primary care and make no more errors than physicians in such settings.

In particular, the IOM reviewed recent efforts by the Department of Veterans Affairs to leverage its nursing labor force as part of a strategy to meet a sudden surge in demand for health services, just as we expect the Affordable Care Act to create on a national level. The Veterans’ Healthcare Eligibility Reform Act of 1996 doubled the number of enrollees in military healthcare programs over an eight year period. To accommodate the anticipated deluge, the VA redesigned its care systems from an old-school, hospital based acute care model to a community based delivery model. Central to the redesign were greatly expanded responsibilities of nurses in the system.

When the non-partisan Congressional Budget Office studied the VA experience, it found that the redesigned system allowed more veterans to receive appropriate care than matched controls in the Medicare program. The new system also cut the annual increase in health expenditures per beneficiary by more than 50%.

Unsurprisingly, organized medicine has responded to the IOM report with a resounding thumbs down. The data are flawed! The public’s worst fears about health reform will be realized if physician oversight of health care is compromised! Nurses haven’t the expertise to handle complex diagnoses and conditions! No one in their right mind will take up primary care as a profession if these recommendations see the light of day!

What to Do

Frankly, we’re tired of the decades-old turf war between physicians and nurses. The Affordable Care Act is right-minded, socially responsible legislation that can improve access to care for tens of millions of Americans. But it will only work if health professionals work together to transform our health system so as to leverage the existing health care workforce. Physicians and nurses need to begin planning this transformation, and they need to do it now. The surge in demand for health services is isn’t going to be solved by expanding the physician pipeline, period. We see no viable alternative to the IOM’s plan.

Nurses will need to step up to the plate and assume even more active leadership roles than they have to date (hence, the educational recommendations put forth by the IOM).

Physicians and nurses need to recognize that patients expect them to begin collaborative planning right now. A redesigned system that focuses on patients is a lofty, socially responsible goal, the kind of goal that drives people to become health professionals in the first place. And it represents a far better use of their time than protecting turf in a worn-out delivery model that never worked well in the first place.

Whatever care system is decided, it’s going to include advanced practice nurses caring for more patients, and multi-disciplinary care teams that care for much larger patient populations than the existing panels of today’s primary care practitioners.

As for physicians, they are going to sit atop these teams and remain ultimately responsible for patient care; they needn’t worry about that. But they need to set-aside any unreasonable urges they may have to keep things status quo and let this transformation occur. Otherwise, they are going down with the ship.

Glenn Laffel, MD, PhD, is a successful entrepreneur in health information technology. He blogs at Pizaazz.

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22 replies »

  1. The Affordable Care Act is going to change healthcare as we know it. Many changes and cut-backs have already taken place. Due to the high number of Americans who will now have health insurance, there will be a greater need for mid-level providers such as Nurse Practitioners. In order to meet the needs of a greater volume of patients, some changes will need to be made to the Nurse Practitioner’s current scope of practice. This can be a good thing as long as there are safety parameters and protocols in place to make sure people are still getting quality healthcare. So the question is, what steps will need to be taken to re-evaluate the Nurse Practitioner’s scope of practice in order to meet the needs of both the patient and the provider?

  2. I’m agree with Mr. GLENN LAFFEL that there are not enough white coat to care for these millions of people and there is requirement of nurses because every day new kind of diseases are arriving and spreading very fast, but in this case there are fewer number of doctor to care from those diseases, but after these all there is requirement of primary care and attention toward health so for these people must be aware about how to be and stay healthy. There are lots of field of health which require primary concern like dental health, mental health, cardiovascular health and a lot more.

  3. This is a very interesting article. The world needs nurses, advanced practice nurses and doctors. I hope that as time goes on that more nurses choose to further their education to become advanced practice nurses. I hope that in the future more doctors can work collaboratively with advanced practice nurses. There is no easy answer to the shortage of primary care doctors but communication between doctors and nurses can be improved at times. Thanks for sharing your article.

  4. When is someone going to have nerve enough to point to the obvious: The future of health care in America is a multi-layered system (already in place) with the richest beneficiaries getting top-tier care, the great unwashed accessing Medicaid and those in between falling into whatever layer is appropriate according to (a) how sick they are and (b) how much they and their family can afford. Plenty of healthy poor people on Medicaid keep that layer looking respectable. And occasional news stories about stricken children, injured military heroes, and other heart-rending cases (all with happy endings, of course) perpetuate the illusion that EVERYBODY in this country is getting good medical care.
    Meantime, many in the medical community advance the clearly false notion that everyone is in agreement when professionals from top to bottom are just as divided as the rest of the country. Take a look at the variety of opinion here at THCB. Drs. Reece and Goodman are at one end and Drs. Wachter and Berwick are at the other. And among the comments we find opinions ranging from Nate to Mahar and everything in between.
    I am so ready for those professionals choosing concierge medicine to get on with their agenda and let the government do what it does best: take care of those who simply cannot afford that level of care, rationing whatever resources are left among those who cannot afford better. Yes, I use the word “rationing” because that is exactly what the insurance industry does and has always done. That it the principle reason for the existence of insurance, apportioning risk in a way that returns a profit, particularly if you are a TPA.
    Tax-supported NIH does the heavy lifting for research and the private sector markets the results, insuring that those who can best afford the newest results get it first and others will have to wait until the patents expire before more affordable “generics” are available. Those who can afford the latest drugs imagine this is an equitable system but those who cannot know better.
    Medicare beneficiaries sort themselves out according to whatever supplemental plan they can afford. Well-heeled seniors buy top tier coverage and others pray another year that they don’t need more care than they can pay. The alphabet plans have been around for years, hidden behind a smoke screen of private sector obfuscation. And since 2003 Medicare Advantage (a misnomer if ever there was one, since it is neither Medicare nor advantageous if you really get sick) has further clouded the picture.
    And this argument about the availability of doctors and nurses makes me tired. The same people who say there are not enough doctors to care for thirty million new patients often argue at the same time that anyone who gets sick gets treated, one way or another, and the lack of money doesn’t matter. They don’t see the contradiction but they can’t have it both ways: either “everyone is being taken care of” or they are not. I was in the food business and I know baloney when I see it.
    I doubt the argument will be over in my lifetime, but it makes me feel better to say it out loud before I’m gone: if you can’t afford to pay, don’t get sick. And if your medical problems get bigger than you can afford, do what Alan Grayson said: die quickly. What he failed to mention was the other alternative: lose all your assets and throw yourself into the arms of Medicare.
    That, my friends, is the growth sector of health care and that is where the most jobs will be generated in the future. Why? Because the population who can AFFORD to be sick is getting smaller and those who cannot afford better care are becoming more numerous. Those jobs will not pay as well as the concierge practices but hey, like most government jobs the benefits package will be pretty good.

  5. actually the relation of doctor and paramedical staff is very much important, because everybody have its job, and if anybody from them is not doing job properly it would be a problem for the patients, because in job everything matters like attitude, behavior with patient and proper treatment and care if somebody is getting all this then it is good otherwise its nothing but a business of earning money. regards
    http://www.healthncare.tk

  6. HI
    This article is very helpful and things you said its very knowledgeable and helpful for the viewers.we are helping people get relief from neck and back pain .looking forward to see more from you.
    Thanks
    Chris

  7. Will there still be hope to enhance the health care condition of the United State? This morning I have read this blog saying that the health care of the state is killing a lot of people and it is such an alarm to see figures later on. I believe the US government is doing their best about this situation and good luck.

  8. “The Affordable Care Act is right-minded, socially responsible legislation that can improve access to care for tens of millions of Americans. But it will only work if health professionals work together to transform our health system so as to leverage the existing health care workforce”
    Very well said! Health professionals should rest aside their personal quandaries and do what they are supposed to do – help people – to create a steady system.
    Brad Kline
    http://www.addiction-online.net

  9. I’m wondering about Dr. Laffel’s uses of the pronouns “we” and “they.” For example, his first sentence, “we highlighted an unintended consequence of the Affordable Care Act,” and when referring to doctors, that “they need to set-aside any unreasonable urges they may have to keep things status quo and let this transformation occur. Otherwise, they are going down with the ship.” Is Dr. Laffel, as Wikipedia says, “Senior Vice President of Clinical Affairs for Practice Fusion,” and if so, is he speaking for his company?
    Regarding content, I agree that the wise use of physician-extenders is very reasonable, and it seems to me that expansion of that use is happening already. If doctors are concerned that quality will fall, it’s really up to society, as long as doctors are not liable for it. And society doesn’t make decisions as a unit. It seems currently inevitable that quality will fall to some degree, because we apparently can’t stop spending more money than we have for health care that is inadequate for millions. If we want to spread healthcare around, we will have to accept either higher financial costs, radical organizational change (such as single payer), or cheaper practitioners.
    Nevertheless, Dr. Laffel’s comment that doctors will have to “allow the transformation to occur” or they will “go down with the ship” reminds me of so many similar declarations in the past that were made with great confidence and that turned out wrong. Doctors will usually do what they have to in order to keep practicing, usually with their patients’ best interest in mind, and the ones I have known have usually been quite resourceful and creative in their solutions. The best ones know that they don’t possess a crystal ball.

  10. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a5.htm?s_cid=mm5944a5_w
    The CDC weighs in on who is really uninsured. Plenty of people are uninsured by choice, as evidenced herein. They will likely opt-out and pay the penalty under PPACA. Is that an unintended consequence or just rational economics?
    If you haven’t surveyed any small employers lately, you might not know that the results say they will opt out as well. Unintended or intended as a means to raise more tax dollars to pay for the program? Read the Act.
    Nurses won’t solve this problem, but maybe the “rationers” have the answers.
    TRG

  11. Most of my recent care in an ER for chest pain was delivered quite well and very efficiently by a nurse. (www.hubslist.org Nov. 15, 2010) I have no idea whether she had a bachelor’s degree or not. In my experience as a pediatrician, the degree doesn’t make much of a difference. It is the clinical experience and personality of the nurse that makes the big difference.
    Excellent point about not allowing NPs to sign Medicare Home Health Plans of Care. It is a moot, not useful, even harmful CMS rule in today’s practice that can delay care to the patient and reimbursement to the already hard strapped home health agency..

  12. Good luck with this plan!!!
    The road to hell is paved with good intentions. The nursing profession can find out the hard way why that adage is basically above the doorways to every physician’s office in this country.
    Also, given any thought to malpractice coverage issues for all this increased service abilities? Oh, didn’t think that one quite through, eh?!
    Another Obamacare lackey strip in this blog!

  13. “Or the doctor is now a manager who looks at charts in his office and coordinates resources?”
    And that’s going to be VERY attractive as a career path for someone who has slaved through med school and residency to earn the right to provde care for their fellow humans.

  14. “If NPs could sign the POC and make order changes for home health patients, I could see NPs moving into a home health role, which would end up keeping patients out of hospitals and even out of doctor’s offices, because the NP could go to them”
    NPs respond to financial incentives the same way docs do. You get paid zero dollars and zero cents for signing POCs and changing orders; the payment for a home visit barely covers your gas.
    More NPs means more NPs working with proceduralists.

  15. “Reasoning that nurses are cheaper and quicker to produce than doctors, …..”
    Does “cheaper and quicker” imply a lower quality result, or is it “cheaper and quicker”, with the same resulting quality?
    I believe nurses can deliver a large portion of care for most people, and in many settings they already do. I don’t really understand the “team” approach very well. I know “team sport” sounds really good, but what does it mean?
    Do patients still get to see a doctor during their visit? Or the doctor is now a manager who looks at charts in his office and coordinates resources?
    Perhaps physicians are only called in for complex and unusual cases, but who decides if the “case” is unusual and complex?
    Are “teams” reserved for the newly insured (poor), or “community” settings (also poor), while the well insureds still get to have regular physician visits?
    It may be very selfish of me, but if I felt bad enough to seek medical care, I would rather have someone that graduated from medical school and has a few years of experience, try to figure out what is wrong and how to go about fixing it. Very similar to seeking advice from a licensed attorney vs. setting up a meeting with a paralegal (which may be very good and may end up doing a lot of the actual work).

  16. I think a big problem is that we have too many specialists and not enough primary care doctors. The primary reason for this is that specialists are reimbursed at a higher rate. Reduce this disparity and you will have more primary care docs.
    I also think that the idea of using nurses in expanded roles is a good one.

  17. Good thoughts. Here is a case in point. Medicare Home Health patients have to have a Plan of Care (POC). That is a good thing, right? But here is the problem. That POC must be signed by a physician. My point is, it can’t be signed by a nurse practitioner, even if the nurse practitioner is the patient’s primary care provider!
    If NPs could sign the POC and make order changes for home health patients, I could see NPs moving into a home health role, which would end up keeping patients out of hospitals and even out of doctor’s offices, because the NP could go to them (and the value of seeing the patient in his or her own environment unequaled for choosing appropriate care).
    This is just one of many areas where patient care would be improved, and the cost would be decreased by expanding the nurse role.
    In reality, though, CMS is chipping away at the home health budget, even as it cries out for fewer hospital readmissions! Hello?

  18. “Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended the implementation of incentive programs which would assure that 80% of nurses have a bachelor’s degree within 10 years, and that 10% of such nurses enter advanced degree programs.”
    Looked at the pay difference between non-degree and degree nurses? Not much “incentive” to assume greater responsibility is there? The job is the job, having a degree’d nurse does not change her job description, the bed pan still needs to be changed. Nurses have long wanted to elevate their profession to an all degree one, but the pay has never arrived to reward that.

  19. Unintended consequences? What do you mean? PPACA is quite deliberate in reducing health care services, and having too few physicians is part of its goal. Fewer docs, fewer scrips, less diagnosis, less care. Oh, maybe it doesn’t prescribe as such, but anyone can read between the lines. That doesn’t mean it is wrong, just not the current view on care.
    More lower level providers is a great idea, but be careful…there is the same shortage of nurses as there is of doctors, so maybe THAT is the unintended consequence if there is one.
    And all of this talk about multidisplinary teams, electronic records, ACOs and medical homes…we are simply building a larger mess than we already have. Who says in the long run all of this expanded effort to coordinate care for everyone, with teams and masses of data, and shared decision making is even possible? Prove it! Sure, “studies” show that crappy care compared to coordinated care is better, but when does coordinated care become crappy…when it fails to work, right? Remember managed care? Isn’t that what we have tried before and have a form of now? Was it intended, unintended or the result of greed?
    I think anyone who says the PPACA is anything good/bad, is just uninformed. We won’t know for a while how good or bad it is. After the big money grab is over, and the goverment stops printing money to fund it, then maybe we can have a fair review of the results. Unintended consequences are just another way of saying “I didn’t get my piece of the pie”. After all, do you really think those 30+ million uninsured aren’t getting care at all? Really?

  20. I thought you and readers might be interested in these two resources from Community Health Centres (CHCs) in Canada on how to improve collaborative, interprofessional care teams.
    http://cachca-rcaccs.posterous.com/video-interdisciplinary-teams-in-chcs
    http://www.aohc.org/aohc/index.aspx?CategoryID=24&lang=en-CA
    We work closely with US Community Health Centers who are all supported through the Ntl Association of Community Health Centers (NACHC) to deliver a similar model of cutting-edge, interprofessional primary healthcare.
    Your blog is spot on in that team-based care is the future. It has to be. As we move further down that path, it should be encouraging to know that CHCs in the US, Canada and elsewhere have already blazed the trail and shown how to make it work!
    Scott A. Wolfe
    National Coordinator – Canadian Alliance of Community Health Centre Associations (CACHCA)

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