Bad News: Obamacare Is Going to Make the Doctor Shortage Worse

Good News: Seeing physician assistants, nurse practitioners, and other non-physician pros for routine care should help bring down costs.

The doctor shortage means seeing a nurse practitioner, physician assistant, or other non-physician professionals will become more common. (Photo: Getty Images/Thinkstock Images)
Fran Kritz is a freelance writer specializing in health and health policy and lives in Silver Spring, Maryland.

If you had surgery at New York City’s Memorial Sloan-Kettering Cancer Center—one of the top cancer centers in the world—you may not see your surgeon for your post-surgery exam. More and more, it’s likely to be a “surgical assistant,” someone who’s completed years of training and may have even been a member of the surgical team. The surgical assistant gives the report to the surgeon, who can act immediately if there’s a problem and check up later if recovery is going well. Having the assistant has two benefits: It frees up the surgeon to do more surgery or deal with complications; and it can lower costs because the assistant is paid a lot less than the doctor.

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This isn’t a new phenomenon, but it’s one that will likely become more common. Hospitals, clinics, emergency rooms, and medical practices are increasingly using medical and surgical assistants, often referred to as “physician extenders.” That’s important, since, starting in January 2014, the Affordable Care Act will add millions more Americans to the U.S. healthcare system—right at the same time that we’re hearing more urgent reports about a shortage of primary care physicians—internists, family physicians, pediatricians, and geriatricians.

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“After high school graduation, it takes about 12 years to produce a primary care doctor—four years of undergraduate education, four years of medical school, and three to four years of residency training,” says Laura Tobler, who follows primary care for the National Conference of State Legislatures (NCSL), in Washington, D.C. “So increasing the number of primary care doctors is not a quick fix. In the meantime, nurse practitioners and physicians’ assistants, in some states, are assuming more responsibility for delivering primary medical care, especially in underserved communities.”

A 2012 study by the American Association of Medical Colleges predicts a shortfall of 45,000 primary care doctors by 2020, a result of a combination of factors: the many newly insured; a large aging population (i.e., Boomers), who are more likely to go to the doctor; more docs leaving primary care as reimbursements go down; and fewer medical students choosing a primary care specialty because the hours can be longer and the income lower than other medical specialties.

Across the country, though, non-doctor professionals, including nurse practitioners—who get advanced training beyond their initial nursing degree —physician and surgical assistants, and many pharmacists are already providing primary care services to patients, especially in rural areas where there may be few practicing doctors, or, increasingly, none at all. Physician and surgical assistants may do their training as part of a college degree, or go back for an advanced degree, which usually takes two to three years. And, unlike medical school, physician assistants work with patients early on in their training.

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What’s more, an increasing number of pharmacy schools are including primary care training in their curriculum, and many offer a “community pharmacy” residency option that can include training on preventing and treating diabetes, obesity, heart disease and other medical conditions.

Chances are good you’ve already been treated by a physician assistant and just didn’t realize it. Urgent care centers and emergency rooms, for example, often have physician assistants at different points before you reach the examining room. State laws generally allow physician assistants to do physical exams, diagnose and treat illnesses, order and interpret tests, handle preventive services and, in most states, write prescriptions, though just about always under a doctor’s supervision. During an ice storm in Silver Spring, Maryland, several years ago, for example, dozens of patients came in with bruises and breaks from falls on the ice, and physician assistants were pivotal in moving patients along for X-rays and checking them out, freeing up the physicians to care for the seriously injured.

The Affordable Care Act authorizes $50 million for ten nurse-managed primary care clinics in underserved areas, according to the NCSL, and there are hundreds more clinics headed by nurse practitioners. NCSL data shows that nurse practitioners are the fastest-growing group of primary caregivers—increasing at a rate of 9.44 percent per capita, compared to 1.17 percent for physicians. Ten states, many with large rural areas, including Alaska and Montana, allow nurse practitioners to work independently. In June 2012, Secretary of Health and Human Services Kathleen Sebelius announced $32 million in funding to train more than 600 primary care physician assistants. All of these changes mean we're likely to see far more non-physician folks for our healthcare in the months and years to come.

What do you think about the trend toward seeing non-physician healthcare professionals for your care?

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