Here's how to cure the doctor shortage

America has an alarming shortage of primary care physicians, and the problem is worse in rural areas. As the Houston Chronicle noted, new medical schools won’t solve the problem. Here in Texas, 54 counties have 27 doctors to care for more than 255,000 people, who are scattered over more than 60,000 square miles.

Advanced practice registered nurses (APRNs) can help.

According to the Texas Department of Rural Affairs, 231 of 254 counties are designated Partly or Whole-County Medically Underserved. Texas ranks 47th out of 50 for adequacy of primary care services. Texas also has the highest uninsured rate in the country at 17.3 percent.

New medical schools won’t help. It takes at least seven years to produce a primary care physician. Doctors tend to congregate in large urban centers, where the patients, technology and money are. Furthermore, only 47 percent of Texas doctors accept new Medicaid patients, making it even harder for the rural poor to get the care they need.

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The problem is not really a shortage of primary care physicians: it is a shortage of primary care. Primary care can take many forms such as Adolescent Medicine, Family Practice, Geriatrics, General Practice, some Internal Medicine, Pediatrics, School Health as well as Women’s Health. Alternative providers — including APRNs — could improve access to such care, but regulations in Texas and many other states prevent them.

APRNs are registered nurses who, after graduating nursing school, continue their education and training to complete a master’s degree or doctoral program that prepares them for advanced clinical roles, such as administering anesthesia, delivering babies, or providing independent primary care. It includes both diagnosis as well as treatment of common ailments. After hundreds of patient-contact hours required to qualify for the R.N. degree, an APRN is required to train for more than 500 additional clinical hours under the supervision of a physician.

In Texas and other restrictive states, APRNs are not allowed to care for patients to the full extent of their training. The Texas Administrative Code forbids APRNs from prescribing medicines without a contract called a Prescriptive Authority Agreement, whereby a physician “delegates” his or her authority to write a prescription. The APRN must pay for the PAA, which can cost tens of thousands of dollars.

When an APRN works in a major medical center, there is no cost to the nurse. If an APRN wanted to care for a medically underserved population, especially rural Texans and inner-city Medicaid enrollees, they run in to the PAA regulatory and financial barrier.

The rationale for the PAA is patient safety. Texas Medical Association asserts that the PAA provides for oversight to prevent APRN mistakes. President of TMA, Dr. Don Read, wrote that “nurses don’t know what they don’t know,” and “nurses are not physicians.”

Yet there is a wealth of scientific data, including more than 120 published reports reviewed by this author, that proves APRNs who practice primary care independently are safe. After a systematic review of the literature, the Department of Veteran Affairs concluded that, “in primary and urgent care settings, there was no difference in the health status, quality of life, mortality, or hospitalizations favoring either APRN or physician care.”

APRNs never claimed they were physicians, and, no one — neither doctor nor nurse — knows what they don’t know. 

Finally, physicians say their oversight protects patients. But doctors generally only review APRN decisions quarterly — not in real time. And they look at only a small number of APRN records, long after the fact. If the APRN makes a mistake, unlikely as that appears based on evidence, the patient would experience an adverse outcome long before physician review could stop it.

By continuing to require a PAA, Texas is essentially saying to patients that no care is better than APRN care. That is just plain wrong.

Meanwhile, millions of Americans who do not have ready access to primary care continue to suffer the consequences: preventable asthma attacks, progression of heart disease until the patient needs an ICU, and cancer discovered too late to treat. Texas and other states need to release its APRN workforce from regulatory shackles so they can provide care for those who currently have none available.

Dr. Deane Waldman (@systemMD), MD MBA, is the Director of Center for Health Care Policy at Texas Public Policy Foundation.