Thursday, April 18, 2013

NO, NO, NO ON SB 491, 492, AND 493!

Do we as citizens agree to reduce the level of education and training of our physicians while increasing the number of healthcare providers by expanding the healthcare pool to include nurses and others? Some say the Hernandez Trio, SB 491, 492, and 493 would do just that. The critical question is whether so doing  would be advantageous or detrimental to the provision of healthcare generally.

SB 491 would let Nurse Practitioners (NPs) practice medicine on their own, just as physicians do. The argument for so doing is that there is a dearth of physicians especially in rural areas that NPs could fill.
The counter argument is that physicians are better educated and trained in terms of diagnostics, differential diagnosis, and therapeutics, that is, how to distinguish what may seem to be an inocuous illness as opposed to the harbinger of a medical catastrophe. The issue is whether or not the exchange is worth the candle. The probable result of passage of SB 491 is that NPs, once licensed, will skedaddle from rural practice as fast as their physician colleagues and will set up shop where the money is and compete with their more advanced and more highly trained counterparts. THAT'S the underlying issue. The rest is window-dressing.

SB 492 would allow optometrists to act as ophthalmologists without the pesky interval of real honest-to-gosh medical education and training. Under SB 492 optometrists would be allowed to administer and prescribe drugs including controlled substances. Never mind that right now at the same time various task forces are trying to make it increasingly difficult even for well trained physicians to prescribe narcotics. SB 492 implies that full blown medical education is not necessary for safe ophthalmology practice. If one believes that then SB 492 isn't a problem.

SB 493 would allow pharmacists to dispense medications. In some cases, as when a renewal isn't attended to promptly by a physician, pharmacists already do just that. Their argument is that their training in pharmacology is actually more than most physicians get. On the other hand, conveniently ignored is that pharmacists aren't educated or trained in physical diagnosis and often are not equipped to deal with the adverse consequences of medications. The upshot is that they may prescribe and leave it to some physician somewhere to deal with the complications.


"Nurse practitioners battle for right to treat patients" is the title of a piece by Shannon Pettypiece, Bloomberg Businessweek reporter. She describes the predicament of Christy Blanco, Nurse Practitioner in El Paso, who has a doctorate degree in nursing practice. Blanco asserts competence in treating diabetes, asthma, high blood pressure, and other conditions. Blanco's problem is that in Texas she is required to contract with a doctor to sign off on medical charts. By contrast no such requirement  exists in New Mexico so Blanco is considering moving there. In her suboptimally used El Paso office she states she is "spending money and making no profit." Ruefully, she adds, "it is a business."

Yessirree, "it is a business," one that has been learned by managed care organizations and corporate American generally and is about to be upgraded by Accountable Care Organizations and pharmacies that are opening their own clinics to be staffed by nurse practitioners and, maybe, even by some physicians (we don't say "even by some doctors" since in due course the NPs will have doctorate degrees in nursing practice).

Competition is not precluded by Hernandez' three bills. Physicians usually leave Nursing Plans in the hands of nurses. They're not required by law to do so. So if competition is the name of the game, one possibility is for physicians to add nursing practice to their own armamentaria. So doing makes more sense than trying to maintain the status quo. We can expect that universities, ever on the prowl for profitability, just like corporate America anywhere, will hire physicians to teach the nurses and then award them "Equivalency Certifications" suitable for framing and display. Physicians can also construct practices entitled to collective bargaining so they can be on equal footing with the nurses who've developed significant enough clout to be direct members of the AFL-CIO (meanwhile, not far behind, is the Union of American Physicians and Dentists, otherwise known as the UAPD or Local 206 of AFSCME, the largest union within the AFL-CIO).

A little known fact, recently revealed by Stuart Bussey, MD, JD, president of the UAPD is that in 2012 the doctors' union was obliged to negotiate with San Francisco County to raise the salaries of the doctors to equal the salaries of the FNPs. The predicament was a kudo for union power on both sides. Unfortunately for the doctors, their preferred professional associations and societies are not unions and are not allowed to negotiate collectively. The nurses don't suffer from this form of erudite elitism.

Professional education has always been considered the democratic equivalent of royal titledom.  We defer to titles, e.g., "doctor. " The nurses' and optometrists' answer is to upgrade alternative forms of education so that the "doctor" title can be bestowed.  Pushing the fact that the higher education and training that physicians get has intrinisic worth is held to be an elitist argument. The answer is to downgrade elitisim. That's where we're headed: less education, less training, equivalency certification, upgraded titles, and a race to the bottom where money lies in tempting repose.

The Affordable Care Act is supposed to upgrade healthcare for all. The expanded application of SB 491, 492, and 493 will downgrade healthcare for all but will expand access to some form of care. This triumverate of bills allows otherwise well trained professionals to work beyond their levels of training. We anticipate in the long run malpractice premiums will increase to accommodate the addition of suboptimally trained new professionals. We recommend a no vote on SBs 491, 492, and 493.

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