Health Care Future Bright for Nurses. Stinks for Doctors.

There are lots of losers in President Obama’s effort to remake the U.S. health care system, and chief among them are the doctors.  But there are also winners, especially nurses and physician assistants (PAs).  Indeed, nurses and PAs win big in part because doctors lose badly.

Surveys repeatedly show doctors are fed up with low reimbursement rates from Medicare and even lower from Medicaid, which have increasingly led doctors to no longer see new patients in those government-run plans.  For example, a recent Texas Medical Association survey found that “34 percent of Texas doctors either limit the number of Medicare patients they accept or don’t accept any new Medicare patients.”  Even more do not accept patients with Medicaid.

Then there’s the heavy-handed regulations and requirements from both government and private health insurers.  Complying with all those requirements and paperwork creates expensive and time-consuming administrative burdens.  And to top it off, there’s the looming shadow of a high-cost lawsuit if things don’t turn out well.

And that’s all before ObamaCare kicks in, which will exacerbate every one of those problems.  So it’s little wonder that there are physician shortages, especially in lower-paying primary care, and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured.

The increased demand for medical care and lower reimbursements—which is one of the primary ways ObamaCare will try to hold down costs—is a recipe for a mass exodus of doctors willing to practice medicine.  As “Physicians Practice” reported in August from its physician survey: “Nineteen percent say they plan to move to another position in the same field.  An equal amount says they plan to leave medicine—not to retire, but to pursue something new.”

So who will provide the needed care if the doctors exit?  Enter the nurses and physician assistants.

If ObamaCare withstands the Supreme Court challenge and Republicans fail to “repeal and replace” it, more nurses will be called on to provide more care that historically has been provided only by physicians—a trend that is already happening.

As the PBS NewsHour reported last May: “The scope of what nurses can do medically has also been growing for the past decade, at a time when the pool of primary care, or family doctors, has been shrinking. … And more and more are working on their own, especially in poor inner-city neighborhoods and rural areas, where there are few doctors in private practice.”

The U.S. Bureau of Labor Statistics (BLS) predicts that the registered nurse (RN) will be the fastest growing profession between 2008 and 2018.  And the profession is financially rewarding.  The BLS estimates that the average salary for a registered nurse in 2010 was $67,720, or $32.56 an hour.  In 2009 the average salary was $63,750, or $30.65 per hour.  That’s about a 6 percent increase in a bad economy when millions of Americans were just thankful to have a job.

However, as in all professions, some segments do better than others.  A recent survey of 3,000 nurse practitioners conducted by “Advance for NPs and PAs” found full-timers earned $90,770 in 2010.  But nurse practitioners in emergency departments earned on average $104,549.  Good salaries considering that Medscape reports that nearly half of family physicians, with all their additional training and educational expenses, made between $100,000 and $175,000 in 2010.

Because ObamaCare will never bend the health care cost curve down—as the president repeatedly promised it would—something will have to give.  And doctors’ reimbursements will be on the amputation table.

Those payment cuts will surely be politically messy.  Just look at the current fight over Medicare reimbursements.  Yes, Congress is trying to stop the scheduled 27 percent cut in physician reimbursements—part of a 1997 law that says if Medicare grows faster than a certain rate, physician reimbursements must be cut to balance it out.  Because Congress postpones the cut every year, the scheduled cut keeps getting bigger.

That means doctors have received no significant Medicare increase in more than a decade, even though their costs to provide care go up every year.  In effect, the Medicare reimbursement problem has resulted in a 20 percent cut in inflation-adjusted dollars.  But what is an unacceptable cut for physicians could be an attractive increase for lower-earning nurses and PAs, many of whom are willing to take the lead on providing more comprehensive care.

While it may make sense to expand nurse and PA responsibilities, that decision should be made from the bottom up, in the context of doctors and nurses looking for ways to provide quality patient care at a reasonable cost.  It should not be the result of top-down micromanagement and price controls that leave health care providers scrambling to find a way to exist under Washington-imposed regulations.  Yet that’s exactly what ObamaCare will do.

Merrill Matthews is a resident scholar at the Institute for Policy Innovation in Dallas, Texas. This post originally appeared at Forbes.

37 replies »

  1. Doctors shouldn’t be the primary concern at this point. The 30 million Americans who are without insurance are. I believe that this article is bias and should be more reasonable. Doctors shouldn’t have to be paid more to accept patients. I understand that is hard work accepting more patients it is also hard work when citizens cant get to the doctor when they need to. Doctors should be fighting to lower cost and still insure quality healthcare.

  2. I feel bad for seniors because doctors will treat seniors on Medicare with a lower quality of care because they do not get paid as much.

  3. “1. Everybody bitches about MDs not working enough. Hell PAs and NPs put in HALF the number of hours of doctors. Guess how many of them are willing to work nights and weekends? Every MD who works with midlevels knows that they are strictly 9-5 folks”.

    Who complains about MDs not working enough?? You can’t fairly say that PAs and NPs work half the number of hours as doctors. These are a little overstated my friend. There are plenty of NPs and PAs that work nights and take call. You sound frustrated.


  5. Okay, a couple points here for the author:

    1) Love this quote: “and those shortages are only going to get worse if ObamaCare succeeds in getting an estimated 32 million more Americans insured.” More people insured? Oh no!!!!! What a comment to say with our broken managed care system.

    2) “As the PBS NewsHour reported last May: ‘The scope of what nurses can do medically has also been growing for the past decade, at a time when the pool of primary care, or family doctors, has been shrinking. … And more and more are working on their own, especially in poor inner-city neighborhoods and rural areas, where there are few doctors in private practice’.” Two questions: a) How much has the scope of practice grown? Only because PBS reports it, doesn’t mean that it is true. A nurse can’t diagnose, prescribe, and can hardly treat without a physician’s oversight. b) If there are few doctors, what harm is having more nurses?

    3) Comparing salaries is a joke. Do you think that nursing degrees are free? Also, it isn’t cheap to get a Medical Degree…

  6. Obama care or Medicaid expansion which ever we chose to call it is here to help ensure every citizen’s right to health care coverage is met even if in a minimal way. Am really surprised at the fact that we are more concerned with physicians’s reimbursement being cut than the poor masses getting taken care of. if as you mentioned their payment has been going up despite plans to have it down as the cost of health care is going up, then I believe its fair for the physicians gave off a little of what they have been getting with the increase to balance out the present deficit. Bitterness is never the solution as most of our posts are filled with. The bottom line is that every health provider whether nurse, PA or physician pays their fair share of the dues, the nurses do most of the bedside dirty works, the PA do most of the physician’s tons of hospital rounds and in the end the physicians makes the money and the hospitals and equipment hospitals make the most. The bottom line is that physicians had had their fair share of the bulks and no matter what its time for every one to pay. They are not the only ones paying. The nurse based on the new buy overs of smaller firms by large firms are now being paid less. So no matter what, every one should cut out the lamenting act and wonder what the poor masses and working families has been going through in anguish all these years the physicians had been increasing health service charges. Please we should all remember that “we reap what we saw” so physicians sowed high cost of health care and definitely will reap cut to their salaries, but what need be addressed at this time is how much it would cost them.

  7. PAs and NPs working in specialty practices with hospital privileges do not work 9-5 hours. They have office hours, hospital hours and take call after hours. If life was so cush physicians would not hire them. $160K in a subspecialty? Not according to all the national surveys. I’ve been working in a specialty and have not received a raise in almost 5 years. When I started I was making less than I did as a bedside nurse.

  8. Yes very heated and not to enlightening. Perhaps the AMA and its “”ologists” will decide to support the idea of posting the cost per patients per year for all physicians on the internet so in the true Republican free enterprise world patients can compare the cost of seeing a specialist instead of a primary care provider for their cold or ear ache. At least publish the costs for Medicare and Medicaid that I am paying with my taxes. Let the press have fun with the data!

  9. I always laugh every time I hear this nonsense.

    1. Everybody bitches about MDs not working enough. Hell PAs and NPs put in HALF the number of hours of doctors. Guess how many of them are willing to work nights and weekends? Every MD who works with midlevels knows that they are strictly 9-5 folks.

    2. Everybody says that PAs and NPs will take over primary care because MDs dont want it anymore. PAs and NPs are drawn MORE TO SUBSPECIALTIES THAN THE MDS ARE. Consider this — last year the Univ of Texas PA and NP programs graduated 127 midlevels. Guess how many of them went into primary care? ZERO!!!! They all ran to the high dollar surgical subspecialties because they get paid DOUBLE to work in subspecialties compared to primary care. If MDs want to subspecialize, its a minimum of 3 extra years of training. That extra training is NOT REQUIRED for midlevels. So they can choose to make 80k in primary care, or they can 160k in a subspecialty, with ZERO extra training. Guess which one they like better????

  10. Quite a heated debate you have going…I have to say I believe there are definite flaws in the health care legislation. We need MD’s that have the knowledge for treatment, research, etc. Compensation for them has to be higher considering the huge student loan debt that follows them after graduation. Perhaps if the monetary cost to get there was reasonable, more would choose primary care, but right now in that field they could never repay their student loans.

  11. Loved this article, it is sooo true with each word I read. I am currently an LPN in the healthcare field for over 10 years and realized without my Bachelors Degree I will not obtain a wage that is needed to survive or even have the respect deserved in the nursing field. Many MD are deciding to move to another professional due to not enough kick back for the lavous lifestyle they have grown acustomed too!!


  12. Tell you what, when we see legitimate photo opps of your pals Pelosi, Reid, Frank, Kerry, Shumer, or other entrenched political millionaire show us by example they are writing their own checks to help balance the budget and get Americans back on their feet, then you have some legitimate argument. Talk is cheap, and oh so how ironic that line is for what comes out of Washington these days.

    Tell us all, Ms G-A, what is this righteous line that defines greed versus legitimate capital efforts to earn an income, and why is your line right and another’s wrong? And who should get that money, how do you know who is appropriately impovershed, and who is just gaming the system?

    Tell us about your buddy Barack having a 4 million dollar vacation on our dime, while I see kids who didn’t even get a real Christmas gift this year.

    Does anyone who spouts off how great their political party is have a real soul to believe that!? And who in their right mind believes that anyone can change DC as it is now? Start with this simple formula: anyone who has been in office more than 12 years should be shown the door out of Washington. Show of hands now, who is better off now than 12 years ago, that being the year 2000? Hmmm, that crowd out their has more downed heads than upraised arms. Yeesh, maybe there is a trend out there in America, and it ain’t the American dream is sunny and warm.

    PPACA sucks, so did the Iraq war, and you, the public, suck as much as the politicians you keep in office year in and out. 2012 will be a banner year if change and hope stay as they are.


  13. Don’t you above 6 commenters have some porn to be watching to be more productive?

  14. Let’s explore class warfare a wee bit, Dr. D.

    When a CEO of a company that pays minimum wages to most of its employees and simultaneously is taking $10M off the top, goes whining to congress that paying a few more miserable dollars per miserable employee will prevent him from creating jobs, that’s not class warfare.

    When corporations are deciding to keep ever increasing portions of profits in the hands of owners and top executives, while wages for all other employees remain flat for decades, that’s not class warfare.

    When international corporations like GE are manipulating the law to evade paying taxes to the country that made their existence possible, that’s not class warfare.

    When Wall Street engages in plain unadulterated robbery of the public, in full daylight, that’s not class warfare.

    But, when one points out all these events, that is class warfare.

    What class might that be, that is being attacked? The modern day version of the Robber Barons? If so, then yes, class warfare is just fine with me, because this class must once again be dismantled. And no, charity is not the point. A square deal is the point.

    Sample quotations from the stratosphere:

  15. thanks for the validation to my comment “look up hypocrisy and find some of these threads as examples.”

    That’s just great, tell people to give up their income, end a business because someone else does not value it. Your writings ooze of pure democratic commentary, just answer me this, Ms G-A, if you came into some extra money in the past year or so, did you write an extra check to the IRS to clear your conscience and do your part to help rectify the debt?

    If you honestly answer yes, then you are a better person than most, perhaps even including me, but, who’s definition of “excess” is the correct, pure one to go by? And what defines a good person in the end to begin with, I mean, how do we know some millionaire who lives in a lavish home, drives an expensive car, eats at expensive restaurants, does not moonlight out of the public eye and helps out his/her community in ways that aren’t just about making a donation, giving some pentance to a charity?

    It is deeds, not words that define us, and in the end, forcing people to do good at someone else’s terms does not make the participants better people nor invested to go further in a positive way. Class warfare is a terrible process, it only pits man against man, does not encourage cooperation and compromise and sincere investment.

    Face it, extremes of liberalism and conservatism are equal failures for societies that want to progress. Moderation and flexibility are the benchmarks of productivity and optimism, because they allow for tolerance and acceptance. But, desparation leads to poor choice. And we by in large are being lead by people in positions of power that smell the desparation, and will exploit it, cultivate it, and turn it against those who possess it. This is what defines the “greatest culture” of the world?

    When Warren Buffett writes an eight or nine figure check to the US government on his own, even if he demands it be spent in certain areas at the same time, that is an example that could spark much response for the better of our country.

    Haven’t seen or heard that moment yet!!!

  16. Poor Mr. Puzder….
    I wonder what sort of health care his employees have now at $12M per year for some 150,000 employees.
    He is right though “The money to cover our increased expenses will have to come from somewhere”. May I suggest executive compensation as a good source….. and if that’s too difficult, then maybe junk food shouldn’t be so readily available and so cheap, and maybe we don’t need more minimum wage “jobs” in the poisoning of America sector.


  17. Yeah, paying attention to the satire at the end and not what the link raises as alleged concerns why businesses will not hire more people in fear of being hit with more government financial regulations really is going to help this country.

    How about refuting what legitimate business people running companies that employ hundreds to thousands of workers are saying they see and are told by their financial advisors will cut into their bottom line.

    Oh yeah, at this site becoming Occupy Wall Street per net, no one deserves to make a dollar more than what essential expenses allow.

    Look up hypocrisy and find some of these threads as examples!!

  18. Another interesting link to show us all how well thought out and conceived PPACA was, to really help restore the economy at least!


    Hmm, you read this and wonder why the Democraps, er, Democrats did not have PPACA so boldly aligned with their reelection campaigns back in 2010, and not hearing many candidates running in 2012 talk it up so far now.

    Yeah, well you turn to your “leader” in Speader Pelosi and then find out, maybe you should read legislation before you pass it! Funny that term “Speaker”, it seems to be beholden to the person of the party in power who has mastered being able to say alot, just not also performing deeds that match if not overwhelm positively the words.

    Maybe we should call this head of the House “Beaker”, like the Seasame Street character who just goes around going “Beek beek beek beek beek”.

    Or, just have the people in Congress be played back in sound bites like the adults were presented in Peanut shows, you know, “Wha wha whaaa, wha whaaa, whaaa.” Certainly would be more funny to hear, although we all realize in the end the deeds certainly would suck, as history of late shows!!!

  19. Read “Medicine in Denial.” Now available at Amazon.com

    Addresses “practicing at top of licensure” issues, among many others.

    A great, thoughtful read.

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  21. I am sorry Mr. MD, you are too expensive considering I only have a cold. NPs and PAs may not have highest skills and service standard as yours, but there are good ones around who are willing to spend time with me.

  22. It is amazing that people can use the same facts to drawing different conclusions. The facts in this article are correct, but the conclusion is totally out of common logic. I, for one, do not want to see a doctor just to treat my cold or get a physical exam. I prefer far more NP or PA because they are more willing to spend time with me.

  23. I’m just curious, with those of you out there so eager to have non MDS take over health care interventions, have any advice how the following situation should have been handled?:

    Working for a community health care organization, there was a NP who decided to quit because she felt there were unscrupulous behaviors going on with the administration, so this Nurse just walked in on a Monday night and resigned without notice, never to return for any follow up care with her patients, never to return phone calls, not even to sign out to provider colleagues any concerns about patients.

    What would happen if I did this as a physician? How many minutes would it take for a report to the board of oversight in my State to be notified of dereliction of duty? Think there was anything done for this behavior by the NP? You folks think that substitution for doctors is so simple and easy and without consequences, that is one reason why health care is floundering and eroding as is.

    You get what you pay for, if you ignore that simple premise, GOOD LUCK!

  24. Read “idiots in denial”, usual most posts here that talk about PPACA and the ensuing threads that have commenters who try to say how this pathetic legislation will save America.

    Hey Bobby G, read the following link below and tell readers how this is so off base, that what PPACA will do for businesses will make them profitable and restore America. While you do that, tell us also how it will cure cancer and make most Americans embrace preventative medicine and put doctors out of business.

    What, why is Rod Serling standing behind you just ready to bust out laughing?


    Hey, I’m laughing with him, Happy christmas and merry new year, folks!

  25. I’m sure that health care will drastically improve so quickly with RNs and PAs taking over the load. And patients will be so patient and understanding when problems and complications with the care process occur.

    Wow,why didn’t we all think of this 20years ago?

    Those damn villains, doctors. Why aren’t we wearing black coats!?

    Happy freakin’ holidays, may all your providers work the holidays to make sure your peace of mind is maximized! Your RNs & PAs won’t!!!

  26. Here is a solution for you. With or without “ObamaCare” we will need more primary care providers, whose collective reimbursement is a rounding error in the total health care expenditure. Instead of delegating primary care for the masses to non-physicians, in a penny-wise and pound-foolish attempt to reduce costs, just “make” more primary care doctors.

    Open up the medical schools (and add new ones) for primary care specific tracks. We turn away more than half of those applying today.
    Double the number of residencies in primary care, while reducing specialty residencies. There are many foreign trained doctors in this country wasting their education in menial jobs.
    Subsidize medical school tuition AND pay better for residency for primary care.

    There is no need for primary care to devolve to a low paid, low education occupation, and if it does, because we seem to be a rather shortsighted nation, health care costs will go up, since referral to “real doctors” will skyrocket.

    It will also increase what is currently termed “disparities”, since I assure you that the elites passionately and learnedly arguing for/against “ObamaCare” can pay, and will be paying, the extra money for continuing to see top notch doctors.
    It is rather easy to devise large scale cost-effective solutions when they don’t apply to either your own persona or anybody else in your “circles”.

  27. So, it’s clear you don’t like the president. But i’m not sure what you’re advocating for here. Do you want to keep 30 million Americans away from health care? Are you interested in dropping costs? Do you want more nurses and PAs giving comprehensive health care? Do you really think the world could go on as it was? Do doctors deserve a high salary guaranteed to rise no matter what goes on in the economy? You sound like someone who has all their talking points in a folder on the table but are afraid to bring them out. Do you have any solutions that might make sense? Sure, doctors and nurses should be looking for ways to lower costs while maintaining quality. Why aren’t they doing that now? Doctors just have no incentive to lower costs. And, by the way, everyone except doctors have been scrambling to find a way to make a living with ever decreasing income. When did doctors or nurses become immune to that?