Speak by Jan. 17 on Pres. Trump’s Executive Order Regarding NP and PA Unsupervised Practice
This e-mail is in response to the call for comment on the effect of Section 5 in the President’s Executive Order (EO), “Protecting and Strengthening Medicare,” of October 3, 2019, with special reference to the issue of Scope of Practice (SOP) and associated pay parity.
To a very great extent, the President’s order has the support of the Practicing Physicians of America (PPA), an organization representing thousands of physicians, and a part of the Free-to-Care Coalition, now comprised of 37,000 physicians and 3 million citizens.
However, PPA objects to Section 5 of the order.
Section 5, although never explicitly mentioning the Nurse Practitioner (NP), will expand the scope of the NP’s role in the American system of delivering medical care.
In what we say next, we do not wish to be misunderstood. The NP is an important member of a medical team, but the team must be led by someone with far greater clinical training and experience. It is simply impossible to equate the 1,000 clinical hours of an NP’s training with the 20,000 clinical hours of a physician’s training.
Physicians are sometimes criticized for raising this point because it is assumed that their motivation is nothing more than the protection of their turf. In fact, our concerns are far more-securely grounded and serious than that, and require evaluation on the merits.
Actual experience and the accumulating data on the gradually expanding scope of the NP’s role in the American healthcare system paint a troublesome picture.
Impact of Overutilization
As a collective workforce, NPs have been criticized for:
At the very least, those tendencies point ultimately to increases in costs, a fiscal impact that is the very opposite of the presumed intent of Section 5.
Impact Favoring the Corporate Takeover of American Healthcare
The increasing corporatization of American healthcare is an undeniable fact that has no demonstrable benefit whatsoever toward restraining inflation and reducing costs in that sector of the economy—a sector that, to the detriment of the general public, is increasingly dominated by special interests, the lobbying dollar, and the campaign contribution.
• The largely consolidated hospital industry. These corporate entities, already home to more than 50% of the nation’s physicians, will be incentivized to replace more and more of those physicians with less-expensive practitioners who have significantly less training.
• Pharmacy chains. The large chains are already deploying “health hubs” in their brick-and-mortar stores. In some cases, these chains own Pharmacy Benefit Managers (PBM) and insurance companies and have already become anti-competitive, vertically merged behemoths. What is to stop them from exploiting the alignment of interests that are inherent within a vertically merged, integrated entity, and draining even more money from the public’s pocket, not only from increased sales of prescriptions and over-the-counter goods, but also from increased profits through the PBMs they own?
Increasing consolidation and quasi-monopolization that continue to create a less-competitive marketplace are inconsistent with the restraint of inflation and a reduction in costs.
Impact on the Deepening Shortage of Physicians
Another, presumably unintended, consequence of Section 5 will be to deepen the already-critical physician shortage.
Section 5’s call for parity of compensation for services will mean that a corporation that employs physicians will have no economic inventive to retain them because the corporation will receive the same amount for a patient’s time with an NP as it will for the same patient’s time with a physician. The NP, however, will be available to the corporate employer at far less cost than a physician.
The long-term effects will be inescapable.
The rate of attrition among physicians will accelerate.
Fewer young adults will step up to replace them because it will make no sense to incur the high tuition of medical school and undergo the years of training that follow.
We will experience shortages among the ranks of well-trained physicians that go far beyond the tens of thousands already expected.
Impact in Fostering a Less-Competent Workforce for Delivering Medical Care
As taxpayers, we must speak against the absurdity of the government spending equal Medicare dollars for the services of highly trained physicians on one hand and on the other hand the same services (or what may appear superficially to be the same services) from practitioners who have a mere fraction of the physicians’ training and expertise.
Even among older NPs, there is dismay over the declining standard of training now being received by younger NPs via diploma-mill programs that are eager to churn out “graduates” with less training, sometimes conducted largely online.
A Cameo Illustrating the Problem
Not long ago, I met a four-month-old patient and his frantic father, a veteran, whose wife was deployed overseas. Less than 18 hours before, an NP in a large, pediatric hospital had sent the child home, despite obvious symptoms of a bowel obstruction, a surgical emergency. The child was now extremely ill and in great danger. Fortunately, this child was transferred to an ICU setting in time and was able to recover after being treated properly.
Nearly every physician I know can tell at least one such story—and sometimes more than one—from personal experience.
Section 5 will accelerate the replacement of physicians with NPs. In turn, that will multiply occurrences like the one described above. It is unavoidable that the outcomes will, in some cases, be tragic.
While we understand that the executive order of October 3, 2019, was meant to push back against proposals of “Medicare for All,” Section 5—with its provisions for an expanded scope of practice for non-physicians and pay parity—will have the particular impact of reinforcing the trend in American healthcare toward corporatization, consolidation, and quasi-monopolization.
The large, special interests will complete the process of turning medicine into big-box operations, with low quality and little discipline from a marketplace in which competition thrives.
Decreased competition is never a prescription for restraining and reducing costs.
Decreased competition means that the choices available to all will shrink; and it will be the choices of the underprivileged that will shrink the most. Factor in the consequences of “pay parity” and it will not be long before ALL AMERICANS are paying more. The foreseeable consequence of higher costs in healthcare will certainly be increased public support for a “Medicare for All” system—the very outcome the executive order was meant to avoid.
A Call to Remove Section 5 from the EO
For the reasons cited above, the Practicing Physicians of America call for Section 5 of the EO to be removed. Its implicit expansion of the scope of practice for a less-qualified workforce and its provision for pay parity among professionals of vastly different levels are threats to America’s health and the ability of a competitive marketplace to discipline the pricing of services.
Our Recommendation of a Better Path
The Practicing Physicians of America ask that all federal measures be aimed at strengthening the eroding foundation that, historically, has been responsible for the high quality of American healthcare.
Increase choices for the public.
Sections B and C of an annotated white paper I was honored to help write in the spring of 2019 offer innovative models for charity care and for expanding access to health care. As a solution to the deepening shortage of physicians, we offer Section D (“Reverse Our Physician Shortage”)
That paper inspired the growth of the Free-to-Care Coalition mentioned above.
The physicians of the Coalition stand ready to speak for our patients and for our profession.
Marion E. Mass, M.D.
Co-founder, on behalf of Practicing Physicians of America