In 18 states (disproportionately but not exclusively rural ones) and the District of Columbia, a nurse practitioner can examine, diagnose, and treat patients in a primary care context. Nurse practitioners also get paid less than doctors. Medicare reimburses them at 85 percent of the doctors' rate, for example, but they also charge less to insurance companies and out-of-pocket patients. And since the "blue states" in this sense are a pretty diverse lot, we can get pretty good quasi-experimental data as to whether cheaper nurse practitioners are actually any worse than primary care doctors in this regard. The answer is a resounding no:
There is a growing body of research demonstrating that patients perceive that receiving primary care and having a usual source of care is more important than who it was that provided these services. 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.
So one great way to improve access to health care would be for the "red" states—California, Texas, New York, Florida, etc.—to "go blue" and change their licensing rules to allow for a wider range of practice by nurse practitioners. It'll help save people money in the short term, and in the longer term it's easier to increase the supply of nurse practitioners (because their training doesn't take as long) and there's plenty of demand for the labor of the "extra" doctors who'd be freed up by letting nurse practitioners do more.
Clayton Christensen, Jeffrey Flier, and Vineeta Vijayaraghavan have a strange Wall Street Journal op-ed out today dumping on the Affordable Care Act's effort to build so-called "accountable care organizations" and instead "beseech[ing] policy makers in Washington to study a range of reform approaches that aren't burdened by as many untenable assumptions as Accountable Care Organizations, and go well beyond them in their aspirations." Those approaches tend to be exactly like what I proposed above—unwinding medical licensing cartels that push prices up and drive supply down. But there's no reason to see this as an alternative to the steps policymakers in Washington are currently taking. In fact, there's relatively little that policymakers in Washington can do about them. These are state-level rules. Congress can meddle in medical licensing rules in D.C., but we're on the side of the angels in terms of nurse practitioners. For states to improve state-level medical licensing, policymakers in Sacramento and Austin need to step up.
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