California Seeks to Address Doctor Shortage With Nurse Practitioners

Published July 10, 2013

Over objections by the state’s medical association, the California State Senate recently passed a health care reform bill intended to address California’s looming physician shortage. The legislators’ solution? Allow nurses to replace doctors in some cases.

SB 491, submitted by Sen. Ed Hernandez (D-West Covina) and passed in May, will allow nurse practitioners (NPs) to provide services consistent with their training and education without the involvement or supervision of a physician.

Fewer Doctors, More Nurses

NPs are advanced practice registered nurses who have completed graduate level education such as a master’s or a doctoral degree. All NPs are registered nurses who have completed additional education and training and have an expanded scope of practice over the traditional registered nurse role.

The idea is that by expanding the role of NPs, California can address its doctor shortage, which will be exacerbated by President Obama’s health care law when it adds up to 7 million new patients into California’s health care system. With the state already experiencing a shortage of primary care physicians, it will not be able to accommodate the coming demand for health care services without expansion of the role of NPs, according to supporters of the bill.

SB 491 will allow NPs to diagnose patients, perform therapeutic procedures, prescribe drugs and devices, and make independent decisions in treating health conditions. It passed by a vote of 21-12 in the Senate and is now under consideration in the Assembly, where it is under fierce opposition from the California Medical Association (CMA), which represents more than 35,000 physicians throughout the state.

Instead of enlarging scope-of-practice for NPs, the CMA suggests California allow for the building of more medical schools and residency slots and expand programs that help doctors pay off student loans in exchange for working in underserved communities.

Expanding Scope of Practice

 Sally Pipes, president and CEO of the Pacific Research Institute, says there is definitely a role for NPs in the new California health care landscape. But she notes that granting greater “scope-of-practice” to non-physicians could jeopardize patient safety.

“I believe there are some new things NPs can do, but there are a lot of things doctors still must do. Can you imagine if you were misdiagnosed by an NP and a lawsuit ensued?” said Pipes.

Pipes says doctor shortages are only going to become more problematic.

“The scarier thing is that the Association of American Medical Colleges reports that 20,000 doctors are retiring earlier than expected. That could quintuple due to the aging of the population, since nearly half of the 800,000-plus doctors in the United States are already over the age of 50,” said Pipes. “Also, reimbursement rates for Medicaid are being cut by cash-strapped states, and ObamaCare starts open enrollment for the health care exchanges in October, throwing more people into the mix. I’m really not surprised that the doctors are getting out now.”

Government Driving Shortages

Dr. Hal Scherz is the president and founder of Docs4PatientCare, a pediatric urologist at Children’s Hospital of Atlanta, and a clinical associate professor of urology at Emory University. He says California’s SB 491 is in line with the federal government’s efforts to change the nation’s health care system.

“In order to do this, they have to expand the scope-of-practice to other members of the health care community who are not doctors,” explained Scherz. “The doctor shortage was created in part because of government reimbursement issues. ObamaCare extends health care coverage to everyone, so it will open up the floodgates to people who will access the system with no regard for who is paying for it.

“In other words, they will have no skin in the game when it comes to paying for their treatment. Overconsumption is inevitable, and as a result it will be absolutely impossible for the Obama administration to deliver on their promises,” Scherz said.

Access to Lower Quality

John Dunn, a physician, lawyer, and policy advisor for The Heartland Institute, says SB 491 is a vision of the future under Obama’s law: an attempt by mid-level health care providers to give the appearance of access to care, even if it’s lower quality.

“Nursing schools are very short on hospital training with patients with serious illnesses. If you don’t have anything serious, you will probably be OK being seen by an NP, in which case you probably don’t need any health care anyway. So this is just an artifice by the government to give the appearance that the health care system is not falling apart,” Dunn said.

Increasing the scope-of-practice to mid-level practitioners is already being done in some states, according to Scherz, with very bad results.

“You may have an optometrist performing eye surgery, or nurse practitioners—because they have an extra year or two of college—identifying themselves as ‘doctors.’ Several states, and California is one, allow psychologists to write prescriptions for psychotropic drugs and commit patients. At Walgreens, the in-store clinics, which are supposed to deal with things like rashes and sore throats, are now diagnosing and treating severe chronic diseases like diabetes,” said Scherz.

“At the end of the day, when you are really sick, who do you want treating you?” Scherz asked.