Are the right people doing the right jobs when it comes to health care? With 1.2 million or more New Yorkers estimated to gain health insurance once health reform is implemented fully in 2014, a key challenge is how to define and differentiate the roles of doctors, nurses, and other health care professionals to meet the growing demand for primary care services. Many say we need to train more primary care doctors. This is a good long-term goal, but in the short term, we need to use all of our primary care professionals as efficiently as possible.
When I talk about a "scope of practice" for health care professionals, people's eyes tend to glaze over, so I like to draw an analogy to auto repair. If there's a headlight out, or a flat tire, you can probably fix that yourself. A routine oil change and many other repairs could be done by somebody trained specifically for those defined tasks. To diagnose what is wrong with your car when it has a complex problem -- a blown transmission, that grinding noise that makes everyone scratch their heads -- you want somebody who knows everything about cars.
Similarly, not every ailment requires a physician's care. Debates are active right now, both in New York State and across the country, about expanding nurse practitioners' scope of practice, but we should be thinking about how to expand the roles of health care professionals at all levels. And primary care is exactly the right place to start, particularly given the health reform law's emphasis on disease prevention and management and on care coordination.
Consider a patient with diabetes, for example, who goes to a community health center for care. Surely, a physician has a role in caring for the patient: making the initial diagnosis of diabetes, diagnosing related problems such as heart disease or kidney disease, and prescribing medication to help manage the symptoms of diabetes.
Other aspects of patient care are already taken on by nurses, who are effective at triaging patients, conducting examinations, and monitoring symptoms. But nurses could also play a more active role in making diagnoses and helping ensure that patients at risk receive the care they need. At least one randomized trial found that the quality of patient care was comparable between physicians and nurse practitioners, and using nurse practitioners is also cost-effective -- nurse practitioners in a physician practice can decrease the cost-per patient visit by as much as a third.
Taking better advantage of nurses' skills and experience will help to expand capacity and increase efficiencies, and free up physicians' time to manage more complicated patients with more complex health conditions.
And as we think about a true health care team, frontline workers such as home health aides, community health workers, diabetes educators, and nursing assistants also have an expanded role to play. Particularly for patients with chronic conditions such as asthma or diabetes, managing the disease goes well beyond the care received in the doctor's office. Frontline health workers are especially well-equipped to provide the education and behavioral counseling that patients need to manage their conditions as they live their daily lives: how to maintain a healthy diet, how to set and reach goals for increased physical activity and a healthy weight, how to adhere to a prescribed medication regimen.
Just as nurses could expand their role to take on some of the tasks that physicians currently perform, frontline workers could have increased responsibility for managing patients' symptoms and monitoring their health. Again, data suggest that doing so would be beneficial both for the quality of care and for reducing health care costs. For example, a community health worker program in Baltimore yielded significant reductions in emergency department visits, hospital admissions, and Medicaid reimbursements among African-American Medicaid patients with diabetes. The program produced a savings of $2,245 per patient per year for a total savings of $262,080 for 117 patients. These workers are effective and cost-effective, and we should do all we can to enhance their reach.
By enabling health care workers at all levels to do what they are capable of doing, and by expanding our mindset about the appropriate scope of practice for a whole range of roles in the health care system, we can create efficiencies and improve care to meet the needs of a growing patient population.
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