Solution to Physician Shortage May Lie in Mid-Level Practitioners

by David Gorn

Ed Hernandez, an optometrist, can see it coming.

The Democrat Senate member from West Covina yesterday helped convene the second hearing in a week to explore the looming shortage of primary care providers in California. The addition of millions of newly insured along with a likely decline in the number of physicians in California is an equation that worries Hernandez. He said the gap is unlikely to be filled in traditional ways.

"Last week we looked at the shortage of providers in California, a shortage that will not lessen," Hernandez said yesterday at a joint meeting of the Senate Committee on Health and the Senate Committee on Business, Professions and Economic Development.

"We're barely meeting the demand now," he said. "One big problem is that 24% [of California physicians] are over the age of 60. … With an ongoing physician shortage, that will require fundamental rethinking of health care roles in California."

The obvious solution is to train more physicians, but that's an expensive proposition. The state hopes to open a UC Riverside medical school, and that could help in the long run, according to Kevin Barnett of the Public Health Institute.

"I have a couple of good news/bad news points: California is first in the nation in retention of those who attended medical school [or residency] here, … but we're 41st in the nation in physicians per capita," Barnett said. "All of this means that California needs to look at other ways to increase the scope of the workforce."

Barnett had a number of recommendations for expanding the current health care provider system:

  • To better recruit and retain providers in underserved areas, the state should look at loan repayment for providers just out of school.
  • Increase the number of residencies in areas that are underserved, since residents often settle in areas where they begin their medical practice.
  • The single best way to increase the capacity of primary care delivery in California, he said, is to expand the scope of practice for less-traditional providers, such as nurse practitioners, physician assistants and others.

"One key point is making sure people are practicing at their full scope of practice," Barnett said. "And where appropriate, look at ways to expand that scope. We have several innovative ways we can test and pilot this to move it forward."

Michael De Rosa, chair of the physician assistant program at Samuel Merritt University in Berkeley, said the California Academy of Physician Assistants is looking into a collaborative training program with the California state university system.

"As we prepare for 2014, PAs are in a unique position to provide for California's primary care needs," De Rosa said, "especially if allowed to work to the scope of our training."

De Rosa said preceptors for PAs currently need to be physicians, and that PA's can't supervise medical assistants. Those restrictions limit work for PA's and put more -- and unnecessary -- work onto the shoulders of physicians, according to De Rosa. Physician assistants don't have signature authority for many things that could make work run more smoothly for physicians.

"We can do the necessary paperwork," he said. "Expanding signature authority would allow PA's to operate more to the level of their training."

Barnett said similar efforts are under way in California to expand the scope of practice for other providers.

San Francisco has an interesting program: a nurse-managed delivery model at Glide Services.

"We see about 3,000 patients a year. Really, we are that diversity that you're looking for in new delivery models," Patricia Dennehy said. "This is the moment to see what we can do differently, to see what is effective care." Dennehy said the facility often partners with other providers, and that can sometimes change the practice of medicine dramatically.

"We need to shift from hospital-based programs into the community," Dennehy said.

One big legislative move, she said would be to list nurse practitioners as providers -- with the compensation from insurance that comes with that designation.

"I'm concerned about [the progress of] health care reform," Dennehy said, "unless NP's are listed as providers. I hope that would be a result of this hearing."

David Gorn
Thank you for the reminders about Ed Hernandez, that is much appreciated. As for the word "mid-level," that is the general term applied to highly trained health care providers who are not physicians. We sometimes use the phrase "advanced practitioners," but since so many types of providers were included in considering the alternatives to care delivery in the hearing, we feel that "mid-level practitioners" is apt.
Jon Roth
The use of the term 'mid-level practitioner' is misleading and disingenuous to training and education of the providers that were discussed during the hearing. Pharmacists, nurse practitioners, physician assistants and optometrists are highly educated health care providers who can help the state prepare for 4-6 million more California's who will be joining the state health program through the implementation of the Affordable Healthcare Act. Also, please note that Dr. Hernandez is not a physician (he is an optometrist), he is not an Assemblymember (he is a Senator) and the hearing was hosted by the Senate Health and Senate Business & Professions Committee. This is sloppy reporting by CHL.
Linda Brokaw
If the Dept. of Labor defines Nurse Practitioners as providers, they would be able to treat injured workers, as they already do, but without required physician signatures on reports.

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