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.