Teamwork to the rescue

Photo | Kristina Falvo Dr. Mike Underwood and nurse practitioner Pat Hall collaborate at the Hartford HealthCare Medical Group in Manchester.

Matthew C. Katz, executive vice president and CEO of the state medical society

Dr. Pamela Aselton

Dr. Jonathan Siegel

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By John A. Lahtinen

The Association of American Medical Colleges predicts that the United States will experience a shortage of more than 90,000 doctors by 2020, including 45,000 primary care physicians.

Expected to exacerbate this is the fact that as many as 30 million more Americans will be provided the opportunity to purchase insurance coverage under the Affordable Care Act (ACA) next year.

A combination of things has led to this impending crisis and it will likely take a combination of approaches to find the right solution.

Several plans have been floated, including the federal Resident Physician Shortage Reduction Act of 2013, which would increase the number of Medicare-supported hospital residency positions by 15,000 over five years.

In Connecticut, the state is adding a new medical school.

At Quinnipiac University in Hamden, the Frank H. Netter MD School of Medicine will welcome its first class this August.

The school was created to train primary care physicians, foster collaborative, team-based care and serve as a national model of inter-professional health professions education. When fully funded, Quinnipiac’s Primary Care Fellowship will waive tuition for every student who commits to practicing primary care for at least four years after they complete their residency training.

Still, adding doctors won’t be enough to meet the demand for services.

Some are seeing teamwork as a viable option.

“If we establish primary care teams that consist of physicians, nurse practitioners, physician assistants, occupational and physical therapists, nutritionists, behavior health specialists, and states allow these individuals to practice at the top of their training, rather than at the top of their license, we will have an exciting and fulfilling work environment for all,” Quinnipiac med school founding dean Dr. Bruce Koeppen recently told federal lawmakers on the Senate Subcommittee on Primary Health and Aging.

There is a strong push nationally to more fully utilize the nearly 200,000 nurse practitioners in the country — about 3,500 in Connecticut.

Training nurse practitioners takes considerably less time than training doctors. A nurse practitioner typically is first licensed as a registered nurse, gains real-world work experience, then completes a master’s degree program. Beginning in 2015, all nurse practitioners will be required to spend an additional year earning a doctorate. Comparatively, a physician program takes four years of medical school and a three- to seven-year residency at a minimum, if not more for specialties.

Some in the medical community argue that nurse practitioners aren’t trained enough to handle the duties of a physician, in effect lowering the standard of care.

In Connecticut, nurse practitioners are required to have a collaborative agreement with a physician in order to practice. In other states, such as neighboring Massachusetts, nurse practitioners are required to have a supervising physician, slightly more restrictive.

During the 2013 legislative session, the Connecticut State Medical Society and physician leaders testified against a bill that would have allowed independent practice for advanced practice registered nurses.

No bill emerged and opinions diverge.

Matthew C. Katz, executive vice president and CEO of the state medical society, says his group certainly recognizes the importance of these nurses as part of the care team, but not as a substitute for a trained and licensed physician.

“The reason for this is not a lack of appreciation or respect for highly-skilled nurses,” Katz said. “It is simply recognition of the fact that physicians and nurse practitioners have significantly different levels of education and clinical training.”

Katz points out that Connecticut has played a role in making the problem more acute.

“The average age of a Connecticut physician is 55,” Katz said. “And although our state ranks fourth in the nation for training physicians (and fourth for training primary care physicians), we rank 45th when it comes to retaining the physicians we train.”

Katz says the annual Medscape “Best and Worst Places to Practice” ratings consistently name Connecticut the worst state in the Northeast region to practice medicine.

“Our liability costs are high, and current tort law provides very few protections for physicians,” Katz said. “Additionally, Connecticut struggles to attract and retain physicians in a state with some of the most restrictive certificate of need laws in the country and a highly concentrated insurance market that makes it difficult for physicians to have strength in the contracting process.”

For nurse practitioners, those challenges are just further evidence they need to be part of the solution.

Dr. Pamela Aselton has taught in the nursing program at the University of St. Joseph in West Hartford for four years and has been the graduate program director in charge of the master’s level programs for family nurse practitioners and the new post-master’s doctor of nursing practice program for the past three years.

Aselton says the movement nationally is to remove the collaboration or supervision requirement as it may limit the ability of nurse practitioners to keep a practice going if the physician they are working with retires.

“The trend in healthcare is inter-professional collaboration and using each healthcare professional to the highest extent possible allowed by their education,” Aselton says. “Nurse practitioners are trained to consult when they feel a case is beyond their scope of practice or experience. Experienced physicians are wonderful resources and their advice is always sought out in caring for unusual cases and critically ill patients.”

Aselton says allowing nurse practitioners to practice more independently and take care of the common illnesses seen in primary care such as colds, sore throats, sprains and urinary tract infections actually frees up the doctors to care for more complicated patients.

She feels the question of nurse practitioner or doctor ultimately comes down to preference.

“There will always be patients who want to only see the doctor, and that is fine,” Aselton says. “I think we are very good about having choices in this country and patients will be free to seek care from other providers. Some older patients are just going to be more comfortable seeing the medical doctor, but in some practices the nurse practitioners have more time to spend with them so they become attached and develop a trusting relationship.”

As doctors struggle with the increased demands and changing business models, not all additional help is welcome.

Dr. Jonathan Siegel, a 15-year family physician who practices with Middlesex Hospital Primary Care in Cromwell, feels the road ahead for doctors is paved with increasing federally mandated requirements, a decrease in autonomy, and an increased need to work within a team-based care model.

He feels strongly that the Affordable Care Act is not the answer, believing it will likely far exceed its predicted costs while doing relatively little to reduce the number of uninsured.

He says a plan allowing individuals 60 years and older to purchase Medicare at reasonable costs would provide a far greater benefit.

“The ACA will undoubtedly create increased mandates and bureaucratic requirements with decrease in reimbursement,” Siegel says. “It does nothing to increase the health consumers’ responsibility for knowing the costs of the healthcare they purchase. Focusing on high deductible health savings accounts would have been far more effective at reducing costs of care.”

Increased regulations and requirements for billing, as well as multiple human resources issues, make managing solo or small physician-run practices increasingly difficult, according to Siegel.

He says many doctors are consolidating to manage overhead or joining hospital-based groups.

“The benefit of consolidation is that it allows physicians more time to focus on patient care and less on office management,” Siegel says. “The downside is that it puts physicians in a position of being managed by non-physician administrators.”

John A. Lahtinen is a freelance writer/editor based in Farmington.