Health reform must address primary care shortcomings

Austin American-Statesman, September 11, 2009

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How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it?

[Editor’s Note: The Truth About Nursing, an international non-profit organization that promotes more accurate media portrayals of nurses, named this article as one of the 2009 Ten Best Media Portrayals of Nursing.]

As a 30-year neonatal intensive care unit nurse, I know that America funds and delivers the finest high-technology care in the world.

But when I admit so many babies of working parents with no insurance and work way too hard to find primary care providers for the babies we send home, I know our country has a terrible problem. It’s a senseless paradox to have easy access to the most complex care yet at the same time have such difficulty accessing preventative care and treatment for acute (fevers, sore throats and the like) and chronic illnesses.

As President Barack Obama said Wednesday night in an address to a joint session of Congress, “Our health care problem is our deficit problem.” Reform should ensure that all Americans have coverage as well as easy access to primary care.

How much healthier would we be and how much more efficiently would we spend health care dollars if everyone could get the care they need when they need it? A recent study reported in the American Journal of Medicine found that in an average-size metropolitan area, each 1 percent increase in the number of primary care physicians led to a decrease of 503 hospital visits, 2,968 emergency room visits and 512 surgeries.

An acute shortage of primary care providers is one of this country’s deep-seated problems. In the 1960s, physicians began opting out of general practice for the more lucrative specialties because of lopsided physician reimbursement.

Counterintuitively, primary care — arguably the most complex specialty — is one of the most poorly reimbursed. As a result, only 2 percent of current medical students — who may well begin practice with $140,000 in loans — plan to take up primary care. That’s down from 14.6 percent in 1992.

Obama’s reform plan more fairly reimburses primary care providers. This country must stop looking solely to physicians to meet primary care needs.

A more sensible, rational way to deliver primary care is through large collaborative practices staffed with physicians, nurse practitioners and physician assistants who are salaried. Nurse practitioners and physician assistants begin careers with far less debt than physicians and are eminently qualified and prepared to offer primary care. They do not hesitate to refer to physician specialists as necessary.

Albeit not primary care, the collaboration of salaried neonatologists, neonatal nurse practitioners and pediatricians and electronic health records functions beautifully where I work in neonatal intensive care. That’s the way Pediatrix, a large, national physician management group, operates.

The Cleveland Clinic that the president visited in July has salaried physicians with no bonuses and annual contracts. These collaborative practices provide high-quality and cost-effective care and should be replicated nationally for primary care in a reformed system.

To meet primary care needs, all qualified providers must be able to practice unencumbered and unfettered. Antiquated regulations constraining nurses’ practice date back to the 1930s when nurses, who were mainly women, were seen as assistants to physicians, who were mostly men. Such contraints include limits on scope of practice, direct reimbursement and prescriptive authority.

Many states have made significant progress in removing barriers, but we are not where we need to be to meet the country’s needs. Individual states must continue to legislatively remove barriers to advanced nurse practice.

Other evolved democracies have realized national imperatives to ensure their citizens have coverage and access to primary care. These countries have empty emergency rooms, save for trauma, heart attacks, strokes and people needing those rare procedures not available elsewhere.

Obama said Wednesday that it is our calling, our character to meet big challenges, that “we did not come here just to clean up crises. We came to build a future.”

Toni Inglis, MSN, RN, CNS, FAAN, is a lifelong Austin resident and retired editor and neonatal intensive care nurse. She writes a monthly opinion column for the Austin American-Statesman editorial page.