Nurse Practitioners Treat Patients Well, Cheaply. So Doctors Want to Stop Them.

 

Health-care costs are up and demand for services will only increase under Obamacare. In many areas, nurse practitioners can provide high-quality care at cheaper costs than traditional doctors.

So why do doctors and other regulators want to clamp down on nurse practitioners?

This video was originally released on December 3, 2013. Go here for more details, resources, and downloadable resources.

Here's the original writeup:

"The major motivation in this opposition is kind of a turf war," says Dale Ann Dorsey, a nurse practitioner (NP) who runs her own women's health clinic in Scottsdale, Arizona.

A nurse practitioner is a registered nurse (RN) who has pursued extra clinical training and a master's degree and is able to practice medicine beyond the scope of what a regular RN can. How far beyond that scope NPs should be allowed to go is a question facing legislators across the country.

Arizona is one of 18 states that allow nurse practitioners to run independent primary care practices, with full prescribing privileges, and without the oversight of a licensed physician. Earlier this year, nurse practitioners in California pushed to liberalize scope-of-practice rules in the Golden State, only to be stopped dead in their tracks by the powerful California Medical Association (CMA), which poured more than $1 million into lobbying efforts in the first half of 2013 to defeat the legislation.

"[Nurse practitioners'] training is very limited compared to physicians," says Paul Phinney, a California pediatrician and former CMA president. "They lack a certain kind of experience that I believe is very important to the safety of patients and the quality of medical care that they're providing." 

He has a point. Physicians are required to obtain far more education and clinical experience than are nurse practitioners. But there's little to no evidence showing that, when it comes to primary care, all of that extra education makes any difference in the health outcomes of patients. A 2012 Health Affairs survey of the medical literature foundno difference in patient health between groups treated by doctors and by nurse practitioners. The survey did find a slightly higher satisfaction rate among patients of nurse practitioners.

So if outcomes are similar, and patients are satisfied, why are states such as California hesitant to let more nurses open their own practices? The question is especially pressing since groups such as the Association of American Medical Colleges are expecting a severe doctor shortage in the near future due to the aging population. Reason Foundation analyst Adam Summers says that concern for the public good is a secondary consideration at best in this case.

"Licensing laws are almost always sold as being in the public interest," says Summers. "But in reality all they do is drive up prices and reduce competition, which reduces the incentive to provide good services to the consumer."

Watch the video to learn more about the nurse practitioners' struggle for clinical independence - a fight that just make health care cheaper and more available.

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Approximately 5 minutes. Produced by Zach Weissmueller. Shot by Tracy Oppenheimer and Weissmueller. Graphics by William Neff.

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  • Christophe||

    Why am I not surprised?

    Also yay NH for being on the right side of the issue.

  • Fist of Etiquette||

    If licensing can stop monks from making coffins, it can stop nurse practitioners from helping to keep us out of them. I don't want to decide for myself whether I trust someone other than a medical doctor to prescribe my antibiotics.

  • straightlinelogic||

    Under Obamacare, waits for doctors visits are only going to get longer as the doctor "shortage" gets worse. If the choice comes down to a NP prescribing my antibiotics now, or a doctor two weeks from now, I'll take my chances with the NP

  • RishJoMo||

    Can we jsut roll that beautiful bean footage already?

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  • Michael Ejercito||

    So there is a war on women after all.

  • Tfo||

    In my experience practicing medicine for 20+ years, nurse practitioners cost the system much more money than a Dr. does treating a theoretical primary care patient: NP's tend to order twice as many tests. (Including $1000. MRI's) and order twice as many speciality Dr. referrals.

    Buyer beware, just because a NP is less expensive, you will probably end up paying much more if you account for for lab tests, radiology tests and speciality referrals.

  • drfredc||

    There's an ongoing fight against evolution to more cost effective models for training effective healthcare providers of all sorts.

    There are evolving models for training health care providers that provide a stepped credentialing system for nurses to become nurse practitioners of one sort or another.

    Yes, NPs don't have the same breadth of background and training as GPs, but they do have enough training to cover most of what they are asked to provide in their NP role. Plus, when some case presents itself that exceeds their knowledge, they do what GPs do -- ask for help...

    Who knows, at some time perhaps the entire nature of how one becomes a medical doctor will have an optional path from traditional medical school -- Credentialling in X number of topics might qualify one to be an MD of some sort -- GP, FP, etc. These topics might basically be the same sorts of topics offered in Medical School for an MD in these fields, only offered in a more cost, time and context effective fashion for currently practicing Nurses and NPs...

    For example, it's one thing to take a 2nd year medical school class in pharmacology when the med student has little to no ongoing contact with patients -- it's another when you're a NP actively engaged in providing care to patients needing medication... Which is going to be better learned and found more relevant to care? The common sense answer is those actively involved in providing care would find the information more relevant...

  • Raghu||

    Full Disclosure: I am a primary-care doctor, and I am a libertarian.

    So, (a) I have a vested interest in criticizing physician "extenders" like physician assistants and nurse practitioners and (b) I am, in principle, opposed to any attempts to regulate them (or any other competitor) out of existence.

    With that said, here are my comments:

    First, the "studies" showing that NP's and PA's can do equivalent or better care compared to PCP's are flawed in several ways. Some were conducted by NP's and PA's for starters, while most primarily select patients in practices with health patient populations. So yes, if you have a runny nose and you see a nurse practitioner, chances are good that the NP won't kill you. He or she will likely prescribe antibiotics you do not need, but you will likely survive and notice no difference in outcome.

  • Raghu||

    Now here comes the problem. Many people go to the doctor wanting to "make sure" they are healthy, i.e. that they don't really have some unusual and/or more serious diagnosis behind the symptoms they present with. This is where NP's and PA's are frankly terrible, in my observation. Like many non-physician providers, they have a tendency to diagnose and treat for things which are familiar, which means if you have something they have never seen or read about, they are more likely to misdiagnose it as something they know how to treat, than to correctly diagnose and refer it out. The flip side of this is that they often refer things out to specialists which can be taken care of by a good primary care doctor. These include things like uncomplicated esophageal reflux, mild intermittent asthma, hypertension, etc. Since specialists are very procedure-oriented, the NP/PA referral patterns actually tend to drive up costs. Unfortunately, I have also found that many insurance-based, primary-care doctors are guilty of the same problem.

  • Raghu||

    A good primary care doctor knows how to recognize situations that are not run-of-the-mill, and knows how to take care of things in a cost-efficient manner. This is something that you will not find in NP/PA clinics, and not in many busy primary care clinics where the emphasis is on seeing large volumes of patients.

  • KimInGA||

    I don't doubt that this is true. The average NP is not going to be as good as a good primary care doctor. But there are lots of not so great primary care doctors. NPs seem like a great option for a lot of the simple stuff: testing for strep throat or a UTI, doing a route physical. I've given up on going to a primary care doctor for the simple tests because it takes so long to get in. The Walgreens clinics are much better. How many primary care doctor visits are really for the complicated stuff, I wonder?

  • Henrycrapcakes||

    What are your thoughts on someone who is a PA but thinks more along the lines of an MD? Granted I know an MD does have more experience/education, but surely you've worked with a PA who has surprised you. I'm currently taking a course run by an NP and she wasn't capable of Calculating dosages correctly. She was suppose to be teaching me and I ended up having to teach this woman with far more education than myself how to write a proper fraction. I want to go into the medical field because of the challenge, but when I challenge an instructor they often tell me it's not my job to know that or it's someone else's job. I don't care if it's not my job I still want the information.

  • Raghu||

    Apropo to the last point, I strongly suspect (without evidence, but based on my 15+ years of clinical experience which also included supervising NP's and PA's) that patient dissatisfaction with doctors vis-a-vis nurses has everything to do with the mass-production, volume-based medical home model that insurance companies have forced onto doctors, and nothing to do with the supposedly equal or better training that nurses are alleged to have. NP's and PA's are entering the market at a time when primary care doctors are now expected to see 30+ patients per day in order to say profitable, which necessarily means less spent time with the patient and more time spent referring the patient for unnecessary specialist evaluations and diagnostics. Most NP's either see fewer patients, or are employed in practice models that emphasize after-hours availability. In other words, it's an apples and oranges argument. If you were to place NP's and PA's in the exact same role as physicians (i.e. managing their own private practices and being responsible for their own business as physicians often are), then it is HIGHLY likely that you will see patient dissatisfaction with NP's go UP, as NP's recognize that they, too, must rush if they expect to be paid.

  • Raghu||

    At the end of the day, people should have the freedom to decide who they wish to see for their healthcare, and providers of healthcare services should represent themselves honestly (it's dishonest for a P.A. to call himself a "doctor" when the average patient is likely to misunderstand that as meaning he is an MD or DO). And it's quite likely that the opposition to NP's is just the same old story of crony capitalism. But that doesn't make NP's "better" or "equal" to doctors, not by a long shot.

  • SamwiseCrackers||

    Seems a ton of MDs in the comments here have their knickers in a twist over this one. Lots of anecdotal claims thrown about. I don't believe the NP in this story implied that NPs are "better" or "equal" to an MD. Just that it should be an option for people.

    The system is broke, we all know it. The cost to the individual is not really worth it. Having to spend $1,000 a month for my family to have access to not even the best possible care is not worth it. So I settle for my $20,000 family deductible $300 a month catastrophic plan, and try to find the most cost effective source for my care. If that be an NP versus an MD, so be it.

    Yet my everyday life is less than joyful with the stress and worry of not being able to pay for the damn system. If I ever reach my deductible my savings are gone. My dreams of buying a house without government support are gone. So really, how is my quality of life better? It's not.

    Only a return to a free market will fix it. But that ain't going to happen, folks. Too many special interests at work. Too many protectionist mentalities at work. Too many people think they are smarter than the invisible hand and think they know best what's best for "we the people".

  • icdogg||

    As a patient with longstanding chronic conditions, I got terrible advice and treatment from plenty of doctors who were supposed to be working for my best health. They asked me to stick to impossible diets and take ridiculous amounts of medication while my conditions only got worse. And when it got worse it was always my failure, never theirs. Which is fine. But if it's going to be my failure, we're doing it my way from now on. And the medical practitioner I'm going to work with is going to work with me, not tell me what to do, no matter what degrees they have. If my life is my responsibility than that's the way it has to be.

    Most importantly, I eat a high fat, low carbohydrate diet. And any doctor or NP or PA that I see has to accept and understand that I am not going to eat sugars, grains, or starches. I will not take any meds that I have not researched and agreed to take. And I will not take statins, period.

    Now I have had a lot of success improving my health doing it my way, and I have managed to find a physician and a NP who think that what I'm doing is great and just want to know what they can do to help. And that's all I want.

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