Common-Sense Solutions: Democratizing Primary Care

While often presented as a single issue, “healthcare reform” is really an umbrella term for a plethora of issues and proposals that all deal, tangentially or directly, with the experience of healthcare in this country. I won’t get into the meat-and-potatoes issues in this post but I will present some prudent changes that most people should and would support.

1.) Abolish Certificate of Need (CON) Laws                                                            

                                                                               SourceNational Conference of State Legislatures                                      

Certificate of Need Laws live up to their acronym: CON. In 1964, New York enacted the first of such laws that requires the state government to determine if there is a need for a new hospital or nursing home before approving the construction of new facilities. The rationale behind these laws was the reigning in of healthcare costs by limiting capital expenditures on health care. Others have contended that the true motive behind these laws is the protection of existing hospitals from competitors. A federal mandate in 1974 required all 50 states to enact CON programs in order to receive funding through the Public Health Service Act. In 1987, the federal mandate was repealed and a wave of states dismantled their CON programs. As illustrated in the above map, 14 states no longer have CON laws.  In states with CON laws still on the books, it can be difficult to nearly impossible to open up new facilities or expand existing ones, burdening the general public with a lack of choice, options, and availability in healthcare.

2.) Allow Nurse Practitioners (NPs) to expand their repertoire                                                                      Interactive Nurse Practitioner Scope of Practice laws chart                                                                                           SourceBarton Associates

According to the American Association of Nurse Practitioners, a Nurse Practitioner (NP) is, in most cases, a primary-care clinician trained on the nursing model as opposed to the physician model. While some NPs do specialize, most provide the fundamentals of care as directed by the nursing model. NPs undergo years of training and must obtain a master’s or doctoral degree and have advanced clinical training. NPs are not to be confused with your average LVN or RN nurses. Many argue that NPs are capable at delivering routine care to patients in a holistic, cost-effective manner with high levels of patient satisfaction. With a looming shortage of physicians and a growing demand placed upon the healthcare infrastructure due to an aging population and the effects of Obamacare, NPs may offer a practical solution. It takes less time and less expense to train an NP than a general practice doctor and it is cheaper to hire and maintain an NP. In my opinion, NPs are a perfect fit because, despite spending less time in training than doctors, more of their training is pertinent to treating the whole person and addressing his everyday health concerns.                                                                                                                                  Still, some groups such as the American Medical Association  oppose expanding the abilities of Nurse Practitioners, ostensibly because they lack the same level of education as physicians. The resistance from the AMA is not surprising as it primarily represents the interests of physicians and doctors. The image posted above links to an interactive chart that illustrates the powers of NPs by state. Some of the battles center on allowing NPs to open up independent practices, order physical therapy, prescribe medications, and sign death certificates. It should be re-stated that patients who see NPs don’t report inferior quality of care. The following excerpt comes from a  2012 brief released by Health Affairs:

Studies comparing the quality of care provided by physicians and nurse practitioners have found that clinical outcomes are similar. For example, a systematic review of 26 studies published since 2000 found that health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians.

What’s more, patients seeing nurse practitioners were also found to have higher levels of satisfaction with their care. Studies found that nurse practitioners do better than physicians on measures related to patient follow up; time spent in consultations; and provision of screening, assessment, and counseling services. The patient-centered nature of nurse practitioner training, which often includes care coordination and sensitivity to the impact on health of social and cultural factors, such as environment and family situation, makes nurse practitioners particularly well prepared for and interested in providing primary care.

3.) Enact comprehensive, common-sense tort reforms 


     At the heart of the debate over medical malpractice is the impact of non-economic damages on the cost of doctors’ liability insurance premiums. Non-economic damages is the term used to refer to the  damages awarded to a plaintiff for the “pain and suffering” caused by the alleged medical malpractice. This is a highly subjective cost as it cannot be measured by lost wages, medical expenses, or necessary care costs. In recent years, headlines have been dominated by tales of plaintiffs being awarded outrageous sums of money in frivolous lawsuits. The result of this indiscriminate awarding of non-economic damages has the adverse effect of forcing insurance companies to raise the premiums that doctors pay for liability insurance. Additionally, doctors  are forced to practice “defensive medicine,” the practice of ordering unnecessary tests or procedures to protect the doctor from the possibility of being sued by patients. These unnecessary tests and procedures further drive the costs of healthcare up.              In response to this onerous burden on good doctors (the majority, I might add), a number of states have placed caps on the size of non-economic damage awards that can be given to a plaintiff in a medical malpractice suit. The above infographic shows states like Texas and California with the tightest caps. Texas, for example, caps non-economic damages at $250,000 per individual plaintiff. In 2003, Texas passed the Medical Malpractice and Tort Reform Act  (HB4) placing the $250k cap on non-economic damages. Other distinctive features of Texas tort law include provisions which allow government entities to be sued (TX Tort Claims Act), forbid the awarding of damages to plaintiffs who have not demonstrated economic losses (no statutory damages), and award negligence claims only if the plaintiff’s liability is 50% or less (comparative negligence).

                                                SourceTexas Medical Board 

Though late to the reform movement, Texas has benefited tremendously from its reforms in a short period of time. According to the Texas Hospital Association (THA), there were 163 actively-practicing physicians per 100,000 population in 2002 in Texas. By 2012, the figure had risen 194 per 100,000 population. More importantly, the growth in practicing physicians per capita in Texas was greater in the period following the 2003 tort reform than in it was in the period preceding the changes. From 2002 to 2012, number of Ob-Gyns per 100,000 increased by 3%, surgeons per 100,000 by 4%, and physicians per 100,000 by 19%. The most deprived and underserved communities in Texas benefited greatly from the increase in doctors. Large swathes of the Texas panhandle, Rio Grande Valley, and various inner-city enclaves witnessed an influx of medical practices, both general and specialty, never before seen.

                                           SourceTexas Medical Board

According to the Texas Medical Liability Trust, the largest liability insurance carrier in the state, the average premium for has decreased by 56.7% between 2003 and 2012.  Doctors and hospitals have reported re-investing the savings in expanding and improving the quality of care they offer. Texas is far from the only medical malpractice success story but it is the most recent example of how a large, diverse polity can successfully pull off tort reform, an example the rest of the U.S would be wise to follow.

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