Obamacare spotlights need for nurse practitioners, physician assistants

This story originally appeared in the Daily News.

His wife caught the flu and was treated at Summit Urgent Care in Palmdale. Then his daughter became ill and sought treatment at the facility. Now it was his turn.

The middle-aged man wearing faded jeans and a green T-shirt stumbled into a treatment room in the early afternoon and told nurse practitioner Donna Emanuele he felt lousy, so lousy that he couldn’t wait for an appointment with his family doctor, which would take several days to obtain.

The man was weak, had a sore throat and cough. Emanuele took his temperature – almost 100 – examined him and obtained a brief medical history. She determined he had the flu and prescribed anti-viral medication and recommended Tylenol for his fever.

Scenes like this will become much more common as millions of Californians obtain health insurance under the Affordable Care Act. There are not enough doctors in many parts of the state, particularly in Palmdale and other underserved areas of Los Angeles County.  Expanding the role of nurse practitioners—who are registered nurses with master of science degrees–and physician assistants—most of whom have undergraduate and masters’ degrees–could help substantially, according to a 2013 RAND Corporation study. 

“You look at Los Angeles County and you see the definition of an underserved area,” said Cynthia Carmona, a director at the Community Clinic Association of Los Angeles County. “With the implementation of the Affordable Care Act, we’ll need all the help we can get.”

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Within limits, both physician assistants and nurse practitioners can treat patients, make diagnoses and write prescriptions.

“Insurance will enable patients to get treatment before their illnesses are so far advanced that it’s almost too late,” said Emanuele, president-elect of the California Association for Nurse Practitioners.

But California is not on the fast track to granting greater autonomy to anyone without a doctor’s license.  Physician assistants must practice under the supervision of a doctor.  And the California Medical Association successfully lobbied against a bill last year that would have enabled nurse practitioners to open their own clinics in areas where physicians are reluctant to establish practices. 

At the Summit clinic, Emanuele works for a team of physicians who are not on site, but are available for consultation.  On a recent Monday Emanuele, an efficient, voluble woman with a cheerful bedside manner, put in a 12-hour shift at Summit. Many of the patients had the flu, colds, sinus infections, or bronchitis; one man injured his knee on a trampoline; a teenage girl had a rash and blisters on her leg and foot; a woman had a urinary tract infection; a middle-aged man needed a physical; a young woman who just gave birth wanted family planning counseling. Emanuele treated most of the patients and prescribed medication. A few she referred to medical specialists.

“In California, we’re facing a massive challenge –- we don’t have enough primary care physicians to meet the need of the Affordable Care Act,” said Kevin Lohenry, director of the physician assistant program at USC’s Keck School of Medicine. “Medical schools aren’t increasing the numbers of students. We can help meet this challenge.”

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Doctor of Nursing (DNP) Donna Emanuele performs a routine pre-operation examinination for Ulysses Lewis Jr. At Summit Urgent Care in Palmdale, Emanuele examines and treats patients with a variety of illnesses during a normal work day seeing as many as 20 patients a day. (Anacleto Rapping / CHCF Center for Health Reporting)

When Lohenry was working as a physician assistant at an internal medicine office in Chicago, he saw twenty to thirty patients a day. His workload eased the pressure on the physicians, he said, and enabled many patients to get treatment in a timely manner, instead of having to wait for appointments.

Supporters of the bill that failed last year say allowing nurse practitioners to work without the direct supervision of a physician will help many newly insured people in rural and under-served areas. The author of the bill, Sen. Ed Hernandez  (D-West Covina), who chairs the Senate Health Committee, said he plans to reintroduce it either this year or next year.

The California Medical Association argues that nurse practitioners need supervision in order to protect patient safety and maintain a high level of care.

“Nurse practitioners were never meant to be a replacement for primary care physicians,” said Dr. Felix Nunez, a CMA member and Chief Medical Officer at Family Health Care Centers of Greater Los Angeles, which has clinics in Bell Gardens, Montebello, Downey and Hawaiian Gardens. “They didn’t go to four years of medical school and complete a residency. I have no problem working with nurse practitioners. But they work best in a team setting. Within that clinical team they are able to provide a high quality of care. That’s what they’re trained to do.”

Still, almost twenty states have passed bills similar to Hernandez’s.  Studies have revealed that the quality of care provided by nurse practitioners and primary care physicians in those states was not appreciably different, said Dylan Roby, an assistant professor at the UCLA Center for Health Policy Research.

“This is a way to improve access,” he said. “Eventually we’ll hit a point when doctors will welcome them taking some of the burden because of all the newly insured people.”

 Critics have said the increased autonomy could lead to a two-tier model of medical care in which the affluent will see physicians and the poor and those living in remote areas will be consigned to nurse practitioners and physician assistants.

“I’m really concerned that standards will not be held up,” Nunez said.

During Emanuele’s shift at Summit, she is the only nurse practitioner on duty and works with three medical assistants. The clinic is located on the ground floor of a medical building and adjacent to a hospital. Inside, there is an X-ray room, a lab where urine and blood samples are taken and tests are conducted for cholesterol levels, anemia, and illnesses including strep throat, flu and mononucleosis. In another section of the clinic, there are a half dozen beds, an EKG machine and a defibrillator.

During a typical shift at Summit, Emanuele – who also works in the emergency room at USC Verdugo Hills Hospital in Glendale – sees about 25 patients a day. After the ACA is fully implemented in California she expects to see double that amount.

“Pretty soon we’re going to have millions of newly insured people and not enough primary care physicians to go around,” Emanuele said. “Who is going to take care of them, particularly in those areas where physicians are reluctant to practice? We feel that we’re certainly part of the answer.”

Corwin is a writer for the California HealthCare Foundation Center for Health Reporting at USC Annenberg.

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