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%. (more…)