Shortages feared in medical field
Amid the implementation of the national health care overhaul, area hospitals may be depending more on nurse practitioners and physician assistants to handle the anticipated influx of insured patients.
One criticism of President Barack Obama’s Affordable Care Act is that the sudden increase in insured patients will create a physician shortage — forcing hospitals to rely more on PA and NP personnel.
Dr. Dale Fell, senior vice president and chief medical officer at Mission Health, said there are significant physician shortages both in Buncombe County and the western North Carolina region.
“When we looked at primary care last year, we were short by about 140 primary care physicians for the 18 counties we serve in western North Carolina,” he said. “Mission Health is currently recruiting cardiologists, general surgeons, neurosurgeons, psychiatrists, specialty surgeons and many others to meet the needs of the region.”
On the other hand, Christina Deidesheimer, director of strategic marketing communications for MedWest Haywood, said MedWest doesn’t suffer from a shortage of qualified physicians because of the quality of life offered in beautiful Haywood County, the quality of the care provided and the caliber of its medical staff.
“We have many specialties represented here that you don’t normally see at a hospital or community our size,” she said.
The only specialty physician MedWest is currently missing is in orthopedics, a recruitment that's due to a recent departure of Dr. Chris Catterson.
“We don’t have a current shortage of mid-level providers but given the changing demographics, primarily an aging population, and changes in how care is provided, we expect to see an increased demand for all primary care providers, both physicians and mid-levels,” Deidesheimer said.
Augmented care team
Whether hospitals experience a further shortage of doctors due to “Obamacare” is yet to be seen, but Deidesheimer said patients should be comfortable with being seen by a NP or PA because they are part of a care team, which includes a physician.
Mary “Charley” McArthur, a PA at Mission Hospital, said the two positions are both considered "mid-level providers" and are licensed health care professionals.
“We provide comprehensive care to patients in all types of medical specialties and settings under the supervision of a physician,” she said.
Although the physician doesn’t physically have to be present, practitioners and assistants have to be able to have a physician to consult with for those more complicated patients.
“I don't think patients should be concerned about being treated by a NP/PA instead of a doctor. Ultimately, a patient should feel comfortable with his/her provider, whether it is a MD, DO, PA or NP and that preference should be respected and honored,” McArthur said. “I find that most patients are open to seeing me instead of a doctor, however if a patient prefers to see a doctor, I respect that wish and do not take it personally.”
Demand in services
Deidesheimer said it would be hard to measure the potential increase in patients and services due to the implementation of the Affordable Care Act. Since North Carolina legislators opted not to expand Medicaid coverage as part of the ACA, many residents will continue to be uninsured.
“That’s because these people don’t meet current Medicaid requirements, but might not be able to afford insurance under the new Health Insurance Marketplace that opens Oct. 1,” she said. “The North Carolina Institute of Medicine says that there are an estimated 8,000 people in Haywood County that would be eligible for the Health Insurance Marketplace, but we can only wait and see.”
Fell also is uncertain of the predicted increase in demand and services starting next year.
“This is the million-dollar question. Western North Carolina’s population is older than that of the state and nation, and therefore western North Carolina has a greater demand for health services overall,” he said, adding that more than 75 percent of Mission’s patients were on Medicare, Medicaid or uninsured. With 20 percent of western North Carolina residents lacking health insurance, Fell said it placed a disproportionate burden on providers in the region.
He said Mission has prepared for an increase in services by having an excellent recruiting team and by working with Mountain Area Health Education Center to try and keep as many of the finishing residents and fellows as possible.
“We are also focusing on retention in many ways, such as helping the new physicians and their spouses settle into the community, enhancing the work environment and trying to assure a good work-life balance,” he said.
Qualifications and abilities
McArthur said PAs and NPs function very similarly and are often qualified to apply for the same jobs.
“Specific job descriptions and responsibilities vary widely depending upon the type of setting, specialty and agreements between the provider and his or her supervising physician,” she added.
NPs require a four-year nursing degree along with work experience as a nurse prior to enrolling in a NP program and upon completion of NP school are awarded a Master's in Nursing. According to McArthur, that will change in 2015 when NPs will be required to have a doctorate degree.
PAs must complete a four-year undergraduate degree and have clinical experience in some type of setting prior to enrolling in PA school. Upon completion of PA school, PAs are commonly awarded a master's of medical science or a master's in physician assistant studies.
Medicare regulations and federal law do not allow PAs or NPs to order hospice and home health care. Depending on the state a PA or NP is practicing in, they may not be able to prescribe controlled substances.
“There are no medications in N.C. that PAs cannot legally prescribe, although there is a limit to prescribing 30 days of controlled substances,” McArthur said.
Is there a cure?
Fell attributes the doctor shortage to many factors. He said primary care is the No. 1 physician search across the nation, creating increased competition for the finishing residents. For the specialists, he has found that many choose to remain at their academic training centers.
“At Mission Health, we are trying to develop innovative models to attract these specialty physicians to Asheville and western North Carolina,” he said. “Uncertainty about the future has caused many groups to delay recruiting additional partners. We are looking at ways to collaborate with them to meet the needs of our patients.”
If Mission does experience a shortage, Fell said the hospital wouldn’t hesitate to rely more on PAs and NPs. He said every practitioner was encouraged to practice at the top of their license so all resources are used.
With a significant shortage of nurse practitioners and physician assistants as well, Fell said Mission Health was collaborating with regional training centers to see how to increase the number of trainees who can live and practice in western North Carolina.
“In health systems with highly integrated care networks, there may be two advanced practitioners for every physician in primary care,” he said. “In western North Carolina, we are closer to 0.5 advanced practitioners per physician.”
While MedWest hasn’t experienced a shortage thus far, Deidesheimer said the matter would be monitored closely.
“Patient safety and quality are always our top priority. To that end, we take measures to ensure that we are always adequately staffed to handle current volume levels,” she said.