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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epperson30Dentists in CalgaryJenniferThomas DahlborgJohn Ballard Recent comment authors
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epperson30
Guest
epperson30

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.… Read more »

Dentists in Calgary
Guest

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… Read more »

Jennifer
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Jennifer

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.

Thomas Dahlborg
Guest

Interesting article. Thank you for sharing. Truly a rift between nurses and doctors exists and truly it must be healed.
http://www.hospitalimpact.org/index.php/2010/10/05/challenging_nurses_and_doctors_to_reach

John Ballard
Guest

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… Read more »

bravomaster
Guest

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

Chris
Guest
Chris

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

Sophie
Guest

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.

Brad Kline
Guest

“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

Dan Urbach, MD
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Dan Urbach, MD

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… Read more »

John Morrow:The Ratings Guy
Guest

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

HMathewson, MD, www.hubslist.org
Guest

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… Read more »

Graham Chiu
Guest

So, nursing staff become the new http://en.wikipedia.org/wiki/Barefoot_doctor of America…. and who will take the place of nurses?

DeterminedMD
Guest
DeterminedMD

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!

pcp
Guest
pcp

“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.