Hospitals need to take a stand on the scope of practice debate

If the implementation of healthcare reform hits any snags, there will be two big ones. The first is the chronic nationwide shortage of physicians to treat all the people with new insurance and Medicaid coverage. The second: The roadblocks put in place when it's suggested anything sensible be done about it.

The most popular suggestion so far is to expand the role of nurse practitioners. They're not physicians, of course, but they have a graduate-level medical education and are allowed in most states to dispense prescriptions and practice many forms of primary care medicine. Nurse practitioners power the hundreds of retail clinics that have sprouted up at chain pharmacies in recent years and staff many of the health centers at colleges and universities. They no doubt will play an ever-larger role in primary care no matter what transpires. They also earn about 60 percent of what a primary care or family medicine doctor does, making them a thrifty alternative to opening more medical schools and trying to recruit physicians from every corner of the country.

Given that more and more physicians are coming under the employ of hospitals, this shortage will soon become a problem that hospital management will eventually own themselves. They're going to have to juggle the paradigm of being penalized for having to readmit sick patients, while possibly lacking the personnel to provide them the type of care that keeps them out of the hospital in the first place.

However, only 17 states have any sort of law allowing nurses to practice with any sort of autonomy, Kaiser Health News recently reported.

Yet despite these inconvenient facts, the American Medical Association and most other state physician lobbies don't care to address the shortage of their members in any manner that would expand the scope of practice for nurses.They see it as a threat to the guarantee every one of their members now have of lifetime employment and stable pay wherever they wish to practice.

Which leads to what recently transpired in California, considered the template-maker for healthcare policy in the rest of the nation.

In the Golden State, the Los Angeles Times reports a bill was recently introduced that would have expanded the scope of practice for nurse practitioners.

Anyone savvy enough to follow the money knew this bill was preordained to fail. Five lawmakers who sat on the first committee the bill had to get through abstained on the first vote. They all received far more contributions from the lobbies that opposed the bill than supported it. Among them is the California Medical Association (CMA), which is arguably the most powerful lobby of any kind in the state.

The CMA not only argued that nurses required more, not less, physician supervision, but created a dedicated Twitter feed to advocate its side.

"Taking on the (doctors) is like taking on labor or the National Rifle Association," the bill's author, Sen. Ed Hernandez,  told theTimes.

That Hernandez said this with a straight face is one of his most remarkable achievements as a politician: He receives about $70,000 a year in rental income from Kaiser Permanente, one of the biggest physician employers in the state.

Introducing the bill gave Hernandez cover for two other pieces of legislation that would expand the scope of practice for pharmacists and optometrists (Hernandez is an optometrist himself). The pharmacist bill has a fighting chance, but all it does is allow them to dispense vaccines and quit-smoking aids. That's the kind of task delegation that doesn't give doctors pause.

A subsequent draft of the nurse bill gutted any provisions for their independent practice. That bill quickly died itself last week.

Hospitals will soon have to decide their role in this debate, and whether they support purely the will of physicians, expansion of primary care services, or a balance of both. I suspect the patient volume shifts that will soon be created by the Affordable Care Act will force hospital management to make up their minds sooner rather than later. – Ron (@FierceHealth)

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