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Free the Nurse Practitioners!

eye on the news

Free the Nurse Practitioners!

A physician shortage is not the same as a shortage of care. May 7, 2015
Andrei Malov/iStock/ThinkStock

For medical students around the country, the third Friday of every March is known as “Match Day,” when they find out if, and where, they will begin their residencies. Not everyone finds a match. Every year, thousands of students fail to gain residency positions, the number of which the federal government caps—even as a physician shortage looms in primary-care specialties such as general medicine, internal medicine, and family practice. The Association of American Medical Colleges estimates that the shortage will reach 45,000 by 2025. In some parts of the country, it’s already hard to find a primary-care doctor.

One seemingly obvious solution for the physician shortage is to increase the number of residency slots. Currently, medical residencies are federally funded through Graduate Medical Education (GME) subsidies, which, in turn, are largely subsidized by Medicare. But the 1997 Balanced Budget Act capped the number of Medicare-funded GME slots at individual hospitals, constraining the growth in positions. In 2012, Medicare contributed about $9.7 billion in GME funding to hospitals to support residency slots, while Medicaid, GME’s second-largest funder, provided almost $4 billion. Some scholars argue that Washington should increase Medicare funding for GMEs, though it’s not clear that doing so will create more residencies. After the BBA-imposed funding restrictions, it’s worth noting, the number of residency slots actually rose.

The real issue is geography. As a 2014 Institute of Medicine (IOM) report observed, the numerical shortage is a result of the regional mismatch of supply and demand for physicians. If doctors avoid certain geographic areas for quality-of-life reasons, or, for that matter, if they aren’t attracted to primary care because of lower income potential, then adding more GME residencies might just result in more doctors flocking to the same big cities to practice highly remunerative specialties.

Fortunately, other options exist to address the regional primary-care physician shortage—which is what we should really be concerned with. The nearly 175,000 nurse practitioners around the country are more than enough to meet our growing primary-care needs, particularly in regions where such care is most needed. These professionals are trained to do just about everything that primary-care physicians do: diagnose illnesses and diseases, determine the proper course of treatment, and facilitate care transitions (for instance, when a hospitalized patient needs to be moved to a nursing home). Moreover, 84 percent of nurse practitioners actively see Medicaid patients—making them crucial players in our health-care system, since, in 2009, half of all physicians either weren’t participating in Medicaid or served fewer than five enrollees.

States often impose tight restrictions on how these medical professionals can practice, requiring “collaborative agreements” with physicians that prevent nurse practitioners from working independently. Physicians’ groups argue that the regulations are necessary, pointing out the 15,000 hours of clinical practice that doctors accrue over seven years of training, compared with the 500 to 700 hours nurse practitioners put in during their graduate training. Yet, a systematic review of 37 studies (including 14 randomized control studies) found no difference in the outcomes of patients treated by nurse practitioners compared with those treated by physicians.

It seems past time, then, to loosen restrictions on the work of nurse practitioners. The IOM should commission an investigation into the long-term effects of replacing physicians with nurse practitioners. And perhaps some of Medicare and Medicaid’s GME funding could be dedicated to providing “bonuses” to hospitals in states that loosen scope-of-practice restrictions. Before Washington throws more money at solving a poorly understood “physician shortage,” it should first understand that a numerical shortage of physicians is not equivalent to a shortage in care.

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