Indian Country and health-care reform: For Native Americans, there's nothing new about seeing nurse practitioners, pharmacists, or others for primary care. Now the rest of the U.S. is catching on.
A family member and I visited a clinic over weekend. First, a nurse, then the doctor, then X-ray, back to the nurse, and finally back to the doctor. The patient took lots of steps. The providers were earnest, carefully asking good questions then filling in the details on the patient’s chart.
But what if one or more steps are eliminated? Well, two things happen: Costs drop, and patient care often improves.
How does less produce more? The answer is to shift the focus of the story — the programming — from the “doctor” to the patient.
At the Alaska Native Medical Center in Anchorage, that relationship is described this way: “With the patient as the hub, the team includes the patient's family, the primary care physician, a nurse case manager, certified medical assistants, case management support, a social worker, and a behavioral health specialist. Additional ‘virtual’ team members include health educators, midwives, nutritionists, and pharmacists. Many specialists (including chiropractors, massage, acupuncture and ‘usual’ medical specialists) are ‘layered’ in."
In day-to-day terms that might mean a patient won’t see a doctor during an office visit — and be the better for it.
In addition to the team approach, there is a growing use of non-physician practitioners of all stripes. The Indian Health Service and affiliate facilities have a long history of using non-physician practitioners as a way to reach more people at less cost. Non-physician practitioners include registered nurses, advance practice nurses, physician assistants, and clinical pharmacists.
At least one major study, funded by the Robert Wood Johnson Foundation, found that the medical experience was about the same for patients who saw non-physician practitioners. The website Marketwatch reported earlier this month that nurse practitioners are one of the fastest growing categories of health care professionals. The article quoted Jeffrey C. Bauer, a medical economist with Chicago-based Affiliated Computer Services Inc., saying one reason is that nurse practitioners spend twice as much time with patients. “That's the No. 1 reason patients who have been to nurse practitioners like them as much or more than seeing physicians.”
Not surprisingly the American Medical Association — representing doctors — suggests a go-slow approach to this alternative for health-care delivery.
The National Congress of American Indians recently published a paper on non-physician practitioners in the Indian Health Service. It reported that IHS has used non-physician practitioners for decades to “stretch limited resources.” However one of the problems is that different offices and facilities have different standards. And an expansion of medical practitioners “would require changes at the local level.”
But even now, before full implementation of the new health-care reform law, the Indian health system has many innovative examples of medical practitioners. My family experienced this 18 years ago when nurse midwives delivered my son at Fort Defiance on the Navajo Nation. (We only realized how much quality time we received from midwives when our second son was born at a hospital where doctor visits were quick and frenetic.)
The range of work by nurse practitioners is extraordinary these days. “For example,” the NCAI paper said, “RNs can work in a hospital-based nursing practice, ambulatory care settings, or in public health nursing. Public health nurses emphasize patient care (especially maternal and child care) and assessment of community needs. They target health education, health promotion/disease prevention, administer immunizations, and make home visits to patients, among other public health services.”
Another primary-care alternative is the pharmacist, especially when patients return regularly for chronic care (such as diabetes, the most expensive disease in America).
“Many pharmacists in the IHS provide broad primary care clinical services, including assuring appropriateness of therapy, providing patient counseling, and disease management for both stable and unstable chronic diseases. These IHS pharmacists perform patient assessment, have various levels of prescriptive authority (initiate, adjust, or discontinue treatment), formulate clinical assessments, develop therapeutic plans, manage chronic disease, and provide many other cognitive clinical services including health promotion, disease prevention, and appropriate coordination of care for follow-up,” the NCAI paper said.
A new primary care network is already under construction. But to make the system work better, the hope is that the new health-care reform law will better coordinate all of this innovation. That means medical schools will be more strategic about professional training, insurance companies and federal providers will pay incentives for primary care by any professional – doctor or practitioner – and there will be better education so that patients understand their place in this framework.
And that means changing the story. We need to look forward to hearing something along the lines of “The medical practitioner will see you now.”