SOLVING THE DOCTOR SHORTAGE
In his piece “Why Is It So Hard to Find a Doctor?” (October 13), Michael Fitzgerald neglected to discuss the critical role of nurse practitioners as primary care providers. Nurse practitioners are board certified, fulfill mandatory clinical hours in their specialties, and are recognized by both Centers for Medicare and Medicaid Services and MassHealth as primary care providers. Yet many of our medical colleagues do not support nurse practitioners assuming the role of primary care provider, despite evidence that nurse practitioners are cost effective and deliver safe, quality primary care. The practice I work in, Commonwealth Community Care, was established more than 30 years ago by a nurse practitioner and a physician to provide home-based care to people with severe physical disabilities. Nurse practitioners provide primary care for patients and function as the leader of this interdisciplinary team. Data collected under a global payment pilot demonstrated $1,400 in cost savings per member per month for those patients managed by nurse practitioners rather than primary care doctors. Failure to discuss nurse practitioners perpetuates the shortage of primary care providers and denies people access to safe, affordable care.
Clinical Director, ICO Programs
Commonwealth Community Care
Does the level of care really require an MD when there are many studies that say primary care given by nurse practitioners is equal to if not better than that given by MDs? Thinking that only MDs can diagnose and provide great health care is an uninformed and outdated perspective when there are more than 155,000 nurse practitioners in the United States giving terrific care now in primary care, cardiology, cardiac surgery, anesthesia, diabetes, nephrology, orthopedics, dermatology, oncology, and other disciplines in hospitals (including Boston) and outside of them. It seems you have bought into and are perpetuating the idea that only MDs should run and give health care because MDs long ago said it should be so.
Acute Care and Primary Care Nurse Practitioner
I was pleased to see team-based care, or the patient-centered medical home, mentioned in Fitzgerald’s story. The patient-centered medical home is an innovative care delivery model that is working to make primary care more efficient, effective, and satisfying to patients and providers. At Atrius Health, primary care doctors are welcoming patients, and all 37 of our medical practices are developing techniques to help physicians use their time more effectively, support patients with a high risk of hospitalization, enhance preventive care, and build stronger connections with specialists. This is the future of primary care, and it will deliver better health and better care at a lower cost.
Dr. Richard Lopez
Chief Medical Officer
Speaking as an economist, it appears that there is a situation of excess demand for primary care physicians. That leaves a puzzle: Why have the salaries of primary care physicians not risen, relative to those of specialists, to clear the market? It also suggests two other solutions that Fitzgerald did not mention: Increase the supply of primary care physicians by making medical education cheaper and by making it easier for foreign-trained physicians to work here. One way to make medical education cheaper would be to start earlier, as is done in many European countries. Instead of requiring a bachelor’s degree first, start medical studies in the first or second year of college. It is also extraordinarily difficult for foreign-educated physicians to get certification in the United States, at least not without extensive further training. And it is difficult to get work visas. The cheapest way to get good primary care physicians might be to tap foreign medical schools. This will require taking on the restrictive practices espoused by the American Medical Association, which understandably seeks to protect the interests of its members, even though this may be at odds with inexpensive medical care for all.
Professor of Economics
“Shortage” is a function of physician supply of and patient demand for medical services. Today’s patients increasingly demand unnecessary physician visits, leading to this apparent — not real — physician shortage. Extensive research suggests that about a third of all medical spending is unnecessary. Examples include redundant tests and follow-up visits, and ill-advised procedures like EKGs on asymptomatic patients. The Choosing Wisely campaign lists dozens more. Rather than increase our physician supply — which the Dartmouth Atlas of Health Care says will make our system worse, not better, due to systemic fragmentation — we need to teach patients how to identify and avoid unnecessary care. Simply increasing our physician supply will add costs and inefficiencies to our already expensive, wasteful system.
Correction Because of incorrect information provided to the Globe Magazine, the average teacher salary in Greenfield in 2010-2011 cited in our October 6 issue was incorrect. The salary was $59,011.
COMMENTS? Write to firstname.lastname@example.org or The Boston Globe Magazine/Comments, PO Box 55819, Boston, MA 02205-5819. Letters are subject to editing.