Vox Medicus

"Vox Medicus," is a periodic feature in DOC-Line that provides a showcase for editorials from members of the medical staff. Members of the medical staff are encouraged to submit editorials to Dr. Matt Miller or Dr. Tom Koobatian.

This issue’s voice is Edward Volpintesta, MD of Bethel Medical Group

The Affordable Care Act and Primary Care Access
Let’s Support APRNs

The physicians reading this issue of DOC-Line, whether working independently or as hospital employees, are now all part of the Western Connecticut Health Network. As a WCHN physician you are aware that the biggest challenge the Affordable Care Act presents for the health system is to find innovative ways to increase the primary care workforce and increase access to primary care.

The Affordable Care Act greatly increases the number of individuals seeking primary care services.  As a result, experts predict that by 2020 there will be a shortage of as many as 60,000 primary care doctors.  Even though some medical schools are shortening their traditional four year programs by one year, it is impossible for them to fill the predicted need.  Part of the solution involves physicians making greater use of advanced practice registered nurses (APRNs). Not only would they greatly increase access for patients but they have the potential to ease the clinical, clerical, and administrative burdens that increasingly fall on the shoulders of Primary Care Physicians.

APRNs can and do perform many important functions. In addition to some basic primary care services like treating upper respiratory infections, sore throats, and earaches, they could, if permitted, independently do insurance physicals, act as school nurses, make house calls, and do post-hospital follow-ups in patients’ homes. These are just a few of the areas APRNs can make a difference in improving patient access to the health care system. They would provide the right care in the right place at the right time.

Currently in Connecticut APRNs are not licensed to practice independently. They must be in collaborative practices with physicians and be “supervised” by them. This needs to change as more and more patients enter the ranks of the insured.

There is a national initiative by APRNs to practice independently. However, the leadership of our medical organizations has not been supportive of this idea. We have shown no enthusiasm, even though APRNs now work collaboratively with many physicians both in the hospital environment and in physicians’ offices.

The most common argument against APRN independent licensing is that Primary Care Physicians have more training than the APRNs.  While true on its face, this argument is misleading. Primary care has undergone a radical transformation in the past two decades. The forerunner of today’s primary care doctor, the general practitioner (GP) did just about everything from delivering babies to taking out appendices. But the rapid expansion of medical science and new surgical techniques made it impossible for general practitioners to remain competent in so many areas.

Add to this the numerous regulations that insurers have placed on physicians and the excessive amount of time that doctors spend with paperwork and it is clear that the role of the primary care doctor has changed radically. Today primary care physicians work mainly in the area of diagnosis and prevention; and coordination and maintenance of care.  Many primary care doctors, who in the early years of their careers had treated a wide variety of illnesses, now find that their days are filled mostly with uncomplicated respiratory illnesses, some bone and joint problems, depression, maintenance of diabetes, stable heart disease, and hypertension. Many only maintain an office practice and no longer take care of hospital patients or nursing home patients.

This new model of primary care makes it plain that well-trained APRNs practicing independently could provide many facets of the care that primary care physicians are now doing.  This could relieve the pressure on emergency rooms where we all know many patients who do not have primary care doctors use for their care.

APRNs are endorsed by the Institute of Medicine (IOM) as qualified to practice independently within the limits of their education and training and because APRNs already are practicing independently in 20 states it is clear that APRNs have a definite role in providing primary care services. The APRNs should be encouraged to practice collaboratively with physicians but those who are willing to accept the challenge of independent practice should be given that responsibility.

I suggest that we physicians – primary care and specialists - take the lead and begin talking with the APRNs. We should seek their ideas with an eye to exploiting and expanding their patient care skills.  A small task force led by the primary care leadership at WCHN would be the ideal starting place to gather information from both physicians and nurses.

We must find a way to meet the challenge of access to primary care for the patients in our communities.

Edward Volpintesta, MD
Bethel Medical Group

evolpintesta@snet.net