WASHINGTON -- The physician shortage will not be solved by allowing nurse practitioners and other advanced practitioners to practice independently without physician supervision, Nicole Johnson, MD, said Monday at a meeting sponsored by the Practicing Physicians of America, a free-market healthcare group.
"Twenty-three states [allow] nurse practitioners to practice unsupervised by physicians," said Johnson, a pediatrician in Cleveland. "Nurses are practicing medicine without a license to do so, and it's dangerous and unsafe for patients." In addition, "they have oversaturated their market and we still need physicians -- they haven't improved access to care and haven't improved affordability -- and this is in the face of a nursing shortage. They need to solve that problem [without] bleeding out the nursing population."
Instead, nurses "should be integrated into physician-led teams and [not act as] physician substitutes," Johnson said.
Some of the physician shortage problem is due to slow production of doctors, she continued. "Medical training is lengthy, so the production rate is going to be slow." And then there is the declining workforce itself, with 40.7% of the physician workforce being ages ≥55.
So what can be done to increase the supply? Increasing medical school enrollment and launching initiatives to attract more medical school graduates to go into primary care, especially in rural areas, would be a good start, Johnson said, noting that 50% of graduates say that their choice of specialty is determined in part by how much money they will make.
"Primary care isn't sexy, and you're not going to make a lot of money," she stated.
Another way to increase physician supply is to increase the number of residency slots available, she continued. Roughly 8,300 students graduate each year from medical school without being matched to a residency slot, "and the gap is growing," Johnson said. To increase the number of slots, Congress should pass a bill to lift the cap on residency positions that was included in the 1997 Balanced Budget Act. This idea -- which is included in several Senate bills -- has bipartisan support; "there is absolutely no reason why we can't make this happen."
In the meantime, six states allow medical school graduates without residency training who have >8,000 hours of hands-on clinical experience to practice under the supervision of licensed physicians, primarily in underserved areas. This licensing program, known as a Graduate Assistant Physician (GAP) license, "is a state issue," said Johnson. "We've got to encourage states to do this."
Making it simpler for doctors to practice in multiple states, especially those who live close to state borders, could also help to ease the shortage, Johnson said. A total of 28 states and one territory have already signed onto an "interstate medical licensure compact" -- "it's a good idea with some bad language," because it ties doctors to participating in Maintenance of Certification programs, she said.
Finally, increasing access to physicians through use of technologies such as telemedicine will also help with the shortage, she added.
Kris Held, MD, an ophthalmologist in San Antonio, Texas, discussed another problem with medical practice: physician burnout, which she said is partly being caused by implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). "When I first read MACRA, I was really stunned," Held said, adding that it helped her to decide to stop accepting insurance at her practice. "MACRA is a Trojan horse for a government takeover of medicine."
Under the MACRA program, physicians can participate in one of two payment tracks in Medicare: they can continue using a fee-for-service system while reporting on various quality measures in their practices in a program known as the Merit-Based Incentive Payment System (MIPS); or they can participate in an alternative payment model such as an accountable care organization.
Held noted that MIPS requires that physicians' quality performance scores be posted on a publicly available website, an idea that she called "a form of public shaming and humiliation ... Using MIPS data is really to control people and control their behavior," Held said. She advocated for repealing MACRA entirely, as the Medicare Payment Advisory Commission (MedPAC) has recommended. But instead of substituting a different program, Congress should "pass new laws [to ease physicians' paperwork burdens]. We can't keep being subject to [MACRA]."
Meeting attendees also were visited briefly by the Department of Housing and Urban Development Secretary Ben Carson, MD, a pediatric neurosurgeon. Carson, who spoke mainly in his role as a physician, advocated for more use of health savings accounts. "A really serious problem is that when somebody's getting medical care, they don't have skin in the game," he said.
"I personally don't believe it's going to be possible, no matter what type of system anybody comes up with, for it to work unless people have skin in the game; that's why I tend to push the whole concept of health savings accounts, because it's so easy for people to see what's going on; accountability and transparency becomes much easier in that situation. If the doctor wants to order five CAT scans on you, you're not going to let him."
Carson also spoke about the relationship between bad housing and poor health. "As a pediatric surgeon in Baltimore, I used to spend a lot of time operating on little babies, trying to give them a second chance at life," he said. "I was often successful -- only to find myself in a terrible dilemma a few days later when I would have to send them home, frequently to a home with lead and mold and rats and roaches, and all kinds of unhealthy things in their environment."
"I'd say, 'I don't want to send them home.' I would sometimes order extra tests to keep them in another day -- don't tell anyone," he said. "Now is the time to do something about those environments; now people are talking about total health -- looking at it in a holistic manner. There are things you don't want [babies] exposed to when their brain is developing."
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