Let me begin by stating that my primary care provider is a nurse practitioner, as is my son’s. My mother’s is a physician’s assistant, and she trusts him more than some of her children. But let’s make something very clear: physicians, nurse practitioners and physician assistants are not the same. They do not receive the same training, do not have the same responsibilities and do not treat the same. They all have their role in health care, but you cannot replace one with the other and expect the cost of treatment to go down and quality to remain the same.
And there is no shortage of primary care physicians.
Walter Russell Mead disagrees. He quotes Amelia Thomson-Deveaux’s piece in American Prospect who argues the solution to this shortage is to allow nurse practitioners to practice on their own without supervision of a doctor.
As you know my wife is a primary care physician (PCP) practicing in a rural underserved area. I’m a systems analyst who once ran a non-profit dedicated to fighting Industry’s efforts to flood the market with cheap H1-b and L-1 visa holders from abroad as they decried a “shortage of IT workers.” There was never a shortage of IT workers, just a shortage of those willing to work for the money IT companies wanted to pay.
Why is it that people become irrational when talking about professionals? If the price of something goes up, it means demand outstrips supply. This is a concept we innately understand. We know that the price will remain high until demand weakens, or the high price encourages producers to expand supply. This combination of reduced demand and increased supply inevitably leads to the price of that something declining. It could be natural gas, LCD televisions or salaries.
There is no shortage of primary care physicians. There is a shortage of PCPs willing to work long hours in disadvantaged areas for less money. I’d love to see where that $189k average PCP salary quoted by Thomson-Deveaux comes from because it sure isn’t paid out here in the Styx. Salaries out here should be higher to encourage docs to come here, and they are somewhat higher than in big metropolitan areas with lots of amenities. But a shortage means salaries are rising, and they should be rising faster out here than elsewhere – but they aren’t. Why not? Because there is no shortage.
The shortage is a myth perpetuated by those who want to manipulate the market to their advantage. Hospitals want nurse practitioners because those in our area are paid $50k per year, roughly 2.5x less than the average PCP salary here, but they bill out at 75% of a PCP. NP associations are working to remove obstacles for allowing NPs to practice unsupervised. That’s fine – as long as physicians aren’t held accountable for their mistakes.
There is a reason a primary care physician goes through 4 years of medical school, followed by 3 years of residency and internship: exposure to a much broader range of conditions and treatment modalities than an NP receives. According to the American Academy of Family Physicians, a family physician receives 21,700 hours of training verses 5,300 for a nurse practitioner. This added training teaches doctors to differentiate between horses and zebras, to know when a condition is presented is either common or uncommon, and to do so without additional tests.
NPs order more tests than physicians, and since those tests are conducted often within their practice or hospital, these tests benefit the providers who pay them. But the cost of that testing is then passed to the insurance company and patient, so they do not benefit from the lower salaries paid to NPs, while the patients suffer the consequences of inexperienced care. Most of the time it won’t matter – remember, I go to an NP as does my teenage son – but I’m healthy as is he. It would be a different matter if one of us were chronically sick.
KevinMD believes this argument between family physicians and nurse practitioners is a red herring. The problems with primary care go way beyond the threat posed to PCPs by nurse practitioners. He cites statistics showing specialists providing 41% of primary care office visits. He believes this is due to patients skipping the gate-keeping role of the PCP and going directly to the specialist because of the perception that they are more qualified. There is no reason for someone with a cough to see a pulmonologist unless he has been directed there by a primary care physician first. This only makes sense because a patient does not incur the cost of seeing the specialist beyond the extra few dollars in the co-pay.
Look, everyone knows the medical system in the USA is a disaster. I’ve lived under socialized medicine (the Kid was even born under it), and I’m not instinctively opposed to it the way some are. But we need to be honest about the problems and avoid scapegoats; there is plenty of blame to go around, starting with the patients themselves. But that’s another essay…