NO: DATA DISPROVE CHANGE IMPROVES ACCESS, LOWERS COSTS

While nurse practitioners (NPS) play a key role in California’s health care system, giving them more autonomy without additional training or oversight poses threats, rather than a solution, for our health care system access needs.

Assembly Bill 890, introduced by Assemblyman Jim Wood, D-santa Rosa, would give NPS autonomy to set up independent practices, but fails to include needed protections for patients to ensure these practicing medical professionals prove basic competency before treating patients absent physician supervision.

Physicians undergo an average of seven to 11 years of post-graduate education (15,000-20,000 clinical hours for family physicians) with a minimum of three years of residency — with some specialties requiring eight-plus years of residency and fellowship — all under the close supervision of licensed, experienced physicians before they can practice independently. AB 890 would allow NPS to act like physicians, but with a fraction of that training (5001,500 current clinical hours, up to 5,000 hours under AB 890).

Proponents of NP independence claim the expansion of their scope will increase access to care and lower the costs of health care for Californians across the state, but the data show otherwise. California patients and policy makers should be under no illusion that this will solve workforce shortages in rural and other medically underserved communities.

In states where physician supervision has been eliminated, there has been no evidence to support claims that NPS move into underserved communities. In fact, federal and census data from 2013-2018 show that even in states without physician oversight, NPS simply practice in the same communities as physicians. In other words, NP independence will not help us provide care to some of the populations with the greatest need in our state.

A 2018 survey found that NP independence may also make it harder for states to retain physicians. Seven of the 10 states with the lowest retention rates of physicians are states that have expanded NP scope of practice. Conversely, seven of the 10 top states for retention of physicians are states that have physician supervision.

Physician retention is important because it helps ensure access to high quality, patient-centric care and reinforces patient protections against the consolidation and corporatization of health care. AB 890 may inadvertently make it harder to keep physicians in California, making our already escalating physician shortage even worse.

The other myth around AB 890 is that it will help control health care costs. A study on “Health Care Expenditures per Capita by State of Residence” from the Henry J. Kaiser Foundation shows that costs increase as consolidation occurs and as NPS are allowed to practice independently.

AB 890 could actually drive up health care costs by promoting more consolidation in the medical community. In recent years, there has been rapid consolidation across the health care landscape with the emergence of large corporate hospital chains and retail pharmacies merging with insurance companies.

Hospital companies support AB 890 because they see it as an end-run around California law, which prohibits doctors from being directly employed by hospitals in order to protect patients and the integrity and autonomy of decision making by the medical professional. This separation of doctors and hospitals helps to ensure patients are protected from profit-driven interests by knowing that medical decisions are made in the examination room, not the corporate board room. AB 890

Federal stats show states that let NPS do more didn’t lift access.

weakens those protections and gives large health care corporations more control over patient care decisions.

States that have removed physician supervision over NPS found that NPS are also more likely than primary care physicians to order expensive imaging services and other tests and prescribe pharmaceuticals at greater rates than physicians. These tests drive up costs and put patients at greater risk for inappropriate procedures and treatments. And even the NPS’ own national organization, the American Association of Nurse Practitioners, in its strategic plan, calls for “parity with physicians and other providers in reimbursement, payment,” further negating any so-called lower cost benefits.

In discussing the future of health care access in California, we must make sure we neither inadvertently drive up costs nor lower training standards. Rather, we must do everything we can to ensure patients have confidence in the competency and training of the medical professionals trusted with their care. Improving access to such care doesn’t require lowering standards. It requires building on the team approach with physician leadership, expanding telemedicine opportunities, and incentivizing physician-led teams of physician assistants and NPS, working at the limits of their training, to work in underserved areas, including correcting the chronic underfunding of Medical, the very program at the heart of rural access shortages.

is a practicing head and neck surgeon in San Diego, and a past president of the California Medical Association and San Diego County Medical Society.