Two Tiered Health: Retail Health Consumers and the Nurse Practitioner

The time has come. A time for which many citizens, both in and out of professional medicine, have awaited with baited breath and white knuckles. One of the lynchpin moments in the last Presidential campaign, drawing ire and criticism from both sides of the political spectrum, President Obama's call for health care reform will in fact pass, for better or for worse. Since the reform, the Affordable Care Act, or ACA, aims to extend insurance coverage to roughly 30 million Americans by 2019, and physicians are gritting their teeth and bracing for a world of diminishing reimbursements and mounting workloads. Still, primary care physicians and patients aren't the only one's who will feel the effects of healthcare reform. Those other healthcare professionals, namely nurse practitioners, are being counted on to help fill in the gaps, to share in carrying the loads, and even expanding their limited duties, due to the surge of the insured population and the physician shortage.

However, not everyone is wholly on board with the suggested change, and more than a few publicized hesitancies have come from within the medical communities. In her article Doctor Shortage Drives Debate Nurse Practitioners, Liv Osby quotes Dr. Roseanne Pruitt in saying that "most of today's physicians came through a system where they are the captain of the ship, and are intimidated by the idea of a nurse practitioner autonomy." In other words, expanding Nurse Practitioner autonomy is interpreted as an encroachment of physician turf by many doctors, and they prefer the traditional "physician led team model."

Still, others consider the idea of patient access when it comes to expanding the role of the Nurse Practitioner, and largely believe it to benefit to those in rural and underserved areas. Amongst these opinions, The American Medical Association maintains a divergent one, insisting that expanding Nurse Practitioner autonomy or creating more flexible practice laws wouldn't really help stop the gap and would introduce new problems to the medical world. The AAFP has taken a public stance against it as well. "Creating a system in which some patients have access to only a nurse practitioner is endorsing two-tiered care," says Dr. Roland Goertz, chairman of AAFP's board of directors. "That doesn't happen in the physician-led, patient-centered medical home, and we believe all Americans should have access to this quality of care." This partisan public stance from the AAFP, insisting that practices should be led by physicians and not nurse practitioners, highlights the idea that many primary care physicians are hoping to establish: their jobs simply aren't replaceable by someone they perceive as less qualified.

Other Shortage Problems
In reaction to Medical School debt and lowered reimbursement, fewer doctors are going into primary care anyway. According to a survey by the nonprofit Center for Studying Health System Change, most of the ideas formulated to help address the physician shortage (such as medical school loan forgiveness and increased reimbursement) still won't help them meet the patient demand. As it stands, there are roughly 300,000 primary care physicians in the United States, with an additional 3,000 new ones entering the workforce annually. With 32 million more insured by 2019, the physician shortage is expected to grow from 25,000 to 45,000 by 2020. Even with optimistic growth estimates, as high as 20%, the survey suggests that only about 6,000 new primary care doctors would enter the workforce by 2020.

The Discerning Patient
Regardless of policy changes, the wheels of the healthcare machine are still ultimately powered by the basic doctor-patient office visit, and a patient's decisions weigh heavily on the cost outcome in a world post-reform. Generally speaking, since Nurse Practitioners have fewer permissions, they offer a more affordable source of patient care than the primary care physician, and can be utilized for patients with more routine visits as a way to cut costs. A recent Accenture survey of 2000 adults younger than 65 years old who were either uninsured, covered by a health insurance policy or covered by a group policy for businesses with fewer than 100 employees marks the term "retail healthcare consumers." Essentially, these are the individuals who will be prime "shoppers" for individual policies in health insurance exchanges when the Affordable Care Act kicks in, in 2014.

Of this swath of citizens, these "retail healthcare consumers," the survey found that affordability tops their lists as the most prevalent concern for healthcare, with 72% listing it as the most important. Surprisingly, only 41% of them said that they'd be willing to visit a Nurse Practitioner for their routine care needs to cut costs. When asked about ways to contain costs, the surveyed participants indicated that they'd change brand prescriptions to a generic to treat the same condition (43%), switch to a new hospital (29%) or switch to a new primary care physician (23%). Essentially speaking, regardless of the fact that these "retail healthcare consumers" will be the biggest healthcare shoppers of the future, and that affordability is their top priority, many of them aren't comfortable with the idea of seeing a Nurse Practitioner over a primary care physician, even if it saves them money in the long run.

Though Nurse Practitioners could close this gap and address the shortage, the fact that almost half of the "healthcare retail consumers" seem unwilling to see them in place of a physician means that physicians could be facing enormous workloads in the years ahead.

Team Efforts and Results-Based Activism
Still, Brian Klepper, PhD finds the divide between the two parties as antithetical to the basis of competent healthcare, and encourages them to work together in his article The AAFP Picks a Fight With Nurse Practitioners saying that "fighting with nurse practitioners will buy primary care physicians little" and that the argument "distracts precious resources from approaches that can keep health care businesses from distorting primary care's appropriate role and specialist from encroaching on primary care's work."

Conclusion
Ultimately, for real change to occur within primary care, and the larger health care system, "results-based activism in policy and the market" must occur (Pho). Primary care doctors must be receiving reimbursements that are adequate on a "full continuum value scale, and must have the compensation and resources to invest in other clinical decision supports tools and management capabilities. These investments, along with clinical data are the real answer to the health care cost problems.

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