As the Affordable Care Act looms large on the minds of health care providers, lawmakers and providers are increasingly calling for less stringent limitations on nonphysicians in order to meet demand spurred by the forthcoming influx of new patients.
In the past three months, a spate of assembly and senate bills have been introduced to address the matter, with state Sen. Ed Hernandez, D-West Covina, introducing a set of bills -- SB 491 through SB 493 -- that would expand practice areas for a number of nurse practitioners, pharmacists, certified nurse mid-wives and optometrists. A separate bill by Sen. Fran Pavley, D-Aurora Hills, would do the same for physician assistants.
Meanwhile, a host of physician advocacy groups unveiled their own set of bills that would address California's well-documented primary care physician shortage without loosening restrictions on non-physicians, among them AB 565, which would expand a student loan repayment program for physicians who practice in medically underserved areas; AB 1176, which would create more residency slots in underserved areas by way of insurer fees; and AB1288, which would place a priority on applications for physicians who practice in medically underserved areas.
The two approaches reflect long-running debate between physicians and non-physicians, although it's less contentious than it has been, local health care experts said.
"It's been an issue for a long time," said Elizabeth Martorana, director of clinical services for Clinic Ole in Napa and a physician's assistant. "I think there's some sentiment that we are looking to replace physicians, but that's not the case." Clinic Ole works in teams of two-to-four primary care providers per patient, Ms. Martorana said, which is more augmentation than replacement.
"When a patient becomes more complex and they start to move out of the scope of practices, they will be transferred or cared for by the team," she said, stressing that physicians assistants and others are clear on not overstepping their training.
The California Medical Association makes clear that is opposes any expansion of practice by non-physicians, saying the "longstanding and highly successful model of providing physician-led, patient-centric care is in jeopardy."
"Mid-level practitioners and other allied health professionals play a significant role in health care, but patients must not substitute them for physicians," reads a statement on the group's website. "Simply expanding the scope of practice of practitioners, without expanded training or education, can mean lowering the standard of care for patients.
Dr. Francisco Trilla, medical director of the eight-location Santa Rosa Community Health Centers, helped develop a nurse practitioner residency program to address the provider shortage. He similarly said that the team approach to primary care, particularly on the nonprofit side, should be embraced and expanded as the health care system seeks to blunt any impact of a provider shortage.
"I think there is broad consensus, certainly more than there was a few years ago, that the primary care provider shortage can only be addressed by primary care teams," he said. "The sentiment is changing. There's still a lot of emphasis that the physician should be the leader, but the resistance is less."
Dr. Trilla said his experience working in Massachusetts when that state passed its universal health coverage law has led him and others to utilize a larger pool of providers. Without it, wait times could negate any hoped-for benefits of health care reform, he said.
"This is a problem that we have projected going back 10 years. I had the opportunity to be in Massachusetts about six or seven years ago, where a much-expanded group of patients needed to be cared for," he said. "And the primary care provider shortage resulted in six-to-nine-month waiting periods."
Santa Rosa Community Health Centers is hoping to expand its nurse practitioner residency. It received a federal grant of $850,000 in 2011 that enabled it to train four residents and this year it's expecting five by mid-summer, Dr. Trilla said.
Mark Knight, a Santa Rosa-based health care consultant, said much of the private sector would likely begin to ask itself if utilizing non-physician providers could help address the physician shortage.
"It will be interesting as these bills become law, assuming they do," Mr. Knight said. "If the legislation changes, you'll see (providers) continue to step up with the use of mid-level providers."
Indeed, the concept isn't entirely new, and some large health systems, like Kaiser Permanente, readily utilize nurse practitioners and physician assistants, both Mr. Knight and Ms. Martorana, of Clinic Ole, said.
"Study after study has shown safe outcomes and improved outcomes," Ms. Martorna said.
Dr. Trilla echoed that notion, saying all primary care providers should be involved in gauging the quality of outcomes.
"The concerns about quality have not been borne out," he said, "Part of the push-back is that (mid-level providers) aren't trained. Well, fine, but let's put resources toward it. Let's be precise and let's define quality."
