health care

When Nurse Practitioners Step in for Doctors

The case for deregulation.


JoNel Aleccia has a good piece at the NBC News website about nurse practitioners providing medical care where there are few or no licensed doctors:

Pre-Code, but not pre-cartel.

Experts estimate the U.S. is already short more than 9,000 primary care physicians, a number expected to rise to 65,800 by 2025, according to the Association of American Medical Colleges….

"To me, nurse practitioners could be a huge, huge solution to this problem of primary care shortage," said Dr. Thomas Bodenheimer, a professor of family and community medicine at the University of California, San Francisco, School of Medicine.

NPs, as they're sometimes known, are registered nurses who hold graduate degrees and can perform virtually all of the functions of front-line family doctors—depending on the laws of the state they're in.

"They can do 90 to 95 percent of what the docs can do," said Bodenheimer, a medical doctor who practiced primary care himself for three decades.

More patients are recognizing that: Between 1998 and 2010, the number of Medicare patients treated by NPs increased 15-fold to more than 450,000 people, University of Texas Medical Branch researchers found recently.

But advocates say that many of the nation's 106,000 nurse practitioners, including about 56,000 who practice primary care, are hamstrung by state laws that limit their authority.

Aleccia notes that there are at least 18 states where these nurses are permitted to "practice independently, without the supervision of physicians." But the doctors' monopoly is strong elsewhere in the U.S., where "so-called 'scope of practice' laws limit NPs' ability to diagnose, treat and prescribe medications without physician supervision."

Read the rest of the piece here. For more on the case for loosening medical licensing laws, go here.

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  1. Not a bad film.

    Meet John Doe era Barbara Stanwyck was Chernobyl hot.

    1. It’s an insane movie. In a good way.

    2. More of a Gene Tierney fan myself. And she played some insane characters.

    3. When I see “Night Nurse”, I get a reggae earworm going. WHo did that song, anyway?

  2. Will that be legal when Obamacare is a fully operational battle station?

  3. I’ve had good luck with NPs. They really can do 90% or more of what a doctor does for a lot less money.

    1. Me too, as I said below.

      1. I’ve had mixed results. I had a very painful throat spasm, felt like something was stuck. The NP I went to subjected me to a whole battery of complicated tests before giving up. I later went out and found an ENT doc, he diagnosed the problem correctly after talking with me for 2 minutes.

        1. Like I said, NPs are good for 90%. Your example required a specialist to solve, so it’s possible a general practitioner would have missed it as well.

          1. Exactly, the NP should have referred the case to a specialist.

            NPs can be excellent for many, if not most, minor ailments. But part of their skill needs to be being able to recognize cases beyond their expertise.

            1. “No, hang on, I GOT this! Lemme try one more time…”

            2. Part of that is the incentive structure created by HMOs

        2. The NP ordered all those tests becasue Nurse Practitioners have very little in the way of rigorous medical training. A very high level of knowledge is required to sort out thirty undifferentiated patients a day but not everybody needs a huge workup and the difference between a physician and a mid-level is knowing who does. NPs are inevitably going to play a big role in the future and like the woman in the article, already do in low service areas. In the meantime, remember that given the choice between the best medical care and the illusion of the best medical care, the money is on the illusion every time because it’s cheaper. If that is the driving force in your decision, go with the NP every time. If not…

          1. My wife is a Family Practice MD and we’ve had this discussion many times. NPs are fantastic when it comes to common, minor illnesses and injuries.

            When it comes to less common or more complex issues, you need an MD who’s been trained to deal with that complexity. The level of education and training that NPs get simply doesn’t prepare them in the same way that 4 years of med school and 3 years of residency does.

            An example is actually my wife’s grandmother. She went to an NP who saw she had high blood pressure like most old folks do. Well she prescribed the strongest BP medication available in order to get it back down to what constitutes normal for a young person. Problem is, according to my wife, as you age and your arteries harden and become partially occluded, you NEED somewhat higher blood pressure to make sure it flows to all the places it’s needed. End result was her grandmother had a stroke and now can’t use the right side of her body.

            That major debilitating condition is directly attributable to someone managing a patient that was far beyond what they were trained to deal with.

            1. Oh yes. I’ve worked with Physician Assistants and Nurse Practitioners in the Emergency Department and have generally enjoyed the experience in the sense that I like having somebody around to help clear out the medical minor-complaint dead wood that chokes every modern ER. But it used to give me heartburn when I’d see some patient with some common symptom that I recognized as a subtle sign of something serious, and thought about what would have happened if the PA or NP had treated and streeted them without their getting to me.

              But, we have to accept that that is exactly what is coming; the tidal wave cannot be managed without greatly increasing the utilization of these middle level folks, bless their hearts. The great advance to universal health care will in fact be the great advance to inferior health care.

        3. I’ve heard the same sort of stories about doctors.

    2. It would be 100%, with the possible exception of surgeries, if the laws were relaxed.

    3. I have yet to use one professionally, but I have found that dates with NPs tend to be more fun.

    4. Don’t forget PAs

  4. My experience with nurse practitioners is significantly better than with GPMDs. They tend to level better with me.
    One of them is the only reason I know that losing 1/3 of my weight is a vanishing rare occurrence. Keeping it off for so long puts me in a group that’s almost non-existent.

  5. It appears to me that this is a ridiculous game of chasing our own tails. We increase the barriers to becoming an MD, so we see an explosion of PAs, DOs, NPs, etc. When we screw these letters up by demanding they all be PhDs with 7 years of post-doctoral work, we’ll invent a new alphabet soup for the people who will do the jobs NPs used to do that MDs did before them. At no point will we question whether we should stop heaping debt and restrictions on our health professionals. Everyone involved will gape in wonder as the system crumbles, but nobody will learn a damned thing or attempt to undo the damage.


    1. It’s as if you can see the future…


    2. Yup. The AANA is pushing for CRNAs to have DNP by 2017. Why have a nurse practioner with a doctorate? Gee I wonder why healthcare is so expensive.

      1. They’re pushing for ARNPs to all have DNP as well.

  6. It’s a shame that Emergency Medical Holograms are only designed as short term supplements to regular medical staff.

    1. How dare you other the Doctor like that?!?

      1. How dare you compare an EMH to a Time Lord!?

  7. But the doctors’ monopoly is strong elsewhere in the U.S., where “so-called ‘scope of practice’ laws limit NPs’ ability to diagnose, treat and prescribe medications without physician supervision.”

    Those doctors have debts to pay!

  8. WE’ve been using NP’s at work (yes, we have our own on site medical) for at least 15 years. Contract with a doc for 4-8 hrs/wk rather than have full time on staff – SIGNIFICANT savings.

    My nurse practitioner umpteen jobs ago is the best direct report I’ve ever had. Great medical person – plus she did my budget, ordered supplies, taught the safety engineers certain processes – stellar. Probably colors my view of NPs overall (positively, of course).

  9. Also, for “THIS ISN’T TWITTER!”


  10. OT: Rand Paul is doing everything he can to earn my support.

    1. I saw that and loved it, too.

      Drones for boozin’, not for killin’.

      1. Namedrop: I met Rand Paul when his Dad ran for prez in ’88 (he went by Randy then).

        We all went out for beers after.

    2. Why couldn’t Rand Paul have been my senator?

  11. OT: Cato gives Dick Durbin the middle finger:…..emies-list

  12. The real question is do any of these NPs have ties to Russia? Do they have the ear of Putin?

    If so…

    1. Boycott nurse practitioners!

  13. I’ve had excellent care from NPs.

    For some things you need a true specialist but for most things a really good NP is going to git’er done.

  14. But who’s going to take on the lower income patients? PAs and NPs snub Medicaid patients even worse than real doctors do. We’re adding up to 17 million new Medicaid patients with the Obamacare expansions, and a lot of talking heads are saying that midlevel non-physician providers are the answer to pick up the slack, but 80% of them won’t currently accept Medicaid.

    From CNBC:

    “while states are under increasing pressure to expand their Medicaid rolls under the Affordable Care Act (ACA), only 43 percent of doctors report that they currently accept Medicaid patients.

    At the same time, physician assistants (PAs) and nurse practitioners (NPs) ? viewed by many as a potential solution to the primary care physician shortage ? report that only 20 percent of them accept Medicaid, raising the question of whether Medicaid expansion will simply leave more Americans insured but with no one to go to for their care.”

    1. Some states don’t let NP bill Medicare directly. CRNAs have to bill under an MD in Florida. Another example of the government getting in the way of open competition.

      1. If nurses are allowed to practice without a doctor’s supervision, then I expect they’ll have to start paying the same malpractice insurance rates that real doctors do? In Florida, that’s the reason they bill under their supervising doctor – it’s the doctor who carries the Med Mal insurance.

        1. CRNAs do have mal practice insurance. I had to pay for my own when I was 1099

          1. Do you carry the same coverage as real anesthesiologists do? Or is it less, since any patient you screw up on can also sue your supervising physician and thus tap into his or her med mal as well?

            1. Captain of the ship doctrine is dead. It lost on the very first trial. Also you don’t have to be supervised by an anesthesiologist, only a physician, including a dentist.

  15. Also, it’s fine if you CHOOSE to see a midlevel rather than a real doctor, but a lot of these new “Patient Centered Medical Homes” and “Accountable Care Organizations” don’t give you that option.

    You pay as much or even more for your health insurance, but you get triaged by the receptionist and if they reckon you’ve only got a “simple” issue, you’re not ALLOWED to see a real doctor.

    Of course, it saves insurance companies and CorpMed a heap of money to funnel 90% of their paying customers (who pay the same, regardless of who they see) to cheaper, less qualified midlevels. Sure, people who want to see a nurse rather than a doctor should be allowed to. But to not be allowed to see your doctor anymore, as is the case in many of these PCMHs, just seems wrong.

    1. ::as an edit, I’d add that I understand that this is more a problem caused by having a third party payor (insurance, the government) involved in the patient-medical practitioner relationship. In a direct-pay situation, maybe patients who would prefer to see a real doctor would pay more; a patient happy to get treated by a nurse would pay less; and it’d be up to the patient to decide the cost/benefit of their choice.

    2. Sure people should have a choice. It people were allowed to pay out of pocket for routine care and carry catastrophic for unforeseen illness then cost would control itself. Want an internal medicine doc pay more, NP pay less. Right now we don’t have a free market in healthcare and thus the increase expense. No real competition.

      1. Yes, we’re agreed on that.

  16. The good news is that with Obamacare, you’ll be able to see a NP. The bad news is that with Obamacare, you’ll have to see a NP.

  17. Given the way insurance masks real costs, of course I’d rather see a doctor than an NP. I pay a $20 co-pay either way. But if we had a fee for service system, I’d choose an NP 90 percent of the time to save money. I rarely go to the doctor because I need something diagnosed. I know my problem going in. I know what medicine I need. I just need a prescription. Same thing for my kids. Especially for ongoing conditions, such as asthma, eczema, high blood pressure…this going in just so the doctor can tell you what you already know and write you a script good for only 6 months so you will have to come back in six months….blah.

  18. Here In Mexico, we have free-enterprise medicine. Even though I pay $23/month for a full policy for serious problems, I mostly go to private clinics or doctors and pay cash–from $2 to $25, depending on the individual doctor. Also, NO PRESCRIPTIONS for medicines or lab work is required. It is so cheap, that we get many medical tourists here at our B&B.

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