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April 21, 2013
Editorial: Chance to take steps ahead on primary care

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(April 21 -- By the Editorial Board)

How should California approach the coming wave of newly insured patients beginning Jan. 1? Anna Reisman, a Connecticut physician who teaches at the Yale School of Medicine, has the right idea: "It's time to unlock the gates to the primary care club. There will be plenty of patients for everyone," she wrote in a Thursday column for slate.com.

Handled properly, that doesn't have to mean reducing standards or "dumbing down" medicine. It doesn't have to mean increased fragmentation or lack of coordinated care. It means making better use of the training of the medical professionals we have, while boosting training to meet the demands of the future.

Today's Senate Business, Professions, and Economic Committee hearing on three bills to expand the role of nurse practitioners, pharmacists and optometrists will set the tone for how California proceeds. All three bills have merits and lapses. More dialogue is needed to identify both the former and latter.

Senators should not rush to pass Senate Bills 491, 492 and 493 out of committee today. Legitimate concerns have been raised that should be considered in some depth. The three bills should be held in that committee so responsible amendments can be aired.

This does not mean that long-standing opponents to an expanded role for nurse practitioners, pharmacists and optometrists should delay the bills in perpetuity. Nor does it mean that proponents should slam these bills through without considering the concerns of those who have taken a "support if amended" or "oppose unless amended" position.

Insisting on a physician-led team in all circumstances is neither practical nor necessary. Physician groups should drop that demand. Currently, nurse practitioners - who have graduate degrees - are not allowed to authorize orders for wheelchairs or prescribe medications without the signature of a supervising physician who may never have seen the patient. That is a bureaucratic morass that is a terrible use of everyone's time.

Nurse practitioners should be able to perform a number of tasks independently in keeping with their educational preparation. Where a situation or condition is beyond their knowledge and experience, of course they should continue to consult and refer patients to physicians - just as primary care physicians do with specialists.

Nurse practitioners also should be able to choose to see Medi-Cal patients. That decision currently is up to supervising physicians.

As Reisman wrote, "nurse practitioners should be released from their arbitrary bondage and do what they are trained to do, what they're board-certified to do, and what many do so well: take care of patients and collaborate with physicians because they want to, not because they have to."

The California Medical Association has a legitimate concern that complaints about nurse practitioners should be referred to expert physician reviewers. That is fixable.

Pharmacists who work in federal agencies such as the Departments of Defense and Veterans Affairs already allow pharmacists to do physical assessments, interpret lab tests, manage chronic disease through medications and partner for follow-up care.

Clearly, details matter. For example, several groups have expressed concern about provisions that would allow pharmacists to adjust or modify prescriptions ordered by a physician. That can be worked it out.

While most groups agree that "some increased role" for optometrists in providing primary health care, there is much room for dialogue and amendment. For example, the bill would allow optometrists to treat not just the ocular manifestations of diabetes, but the illness itself. The California Association of Physician Groups and others recommends changes.

In all these cases, the proper response is continued dialogue between bill authors and medical professionals to come up with solutions - not to scuttle the bills. Unlocking the primary care gates does not mean opening the floodgates. Let the negotiations begin.

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