Ohio faces filling physician shortages in future

By 2020, Ohio is expected to be short by just over 5,000 primary care physicians to take care of basic health needs.

Nurse practitioners could help fill that shortage. But a number of barriers — a lack of nursing instructors at all levels, billing issues, regulatory limitations on practices and an ongoing tug-of-war with physicians over turf and authority — mean there may not be enough nurse practitioners to go around, either.

The shortage of primary care providers, both physicians and advanced practice nurses, comes as the number of people seeking routine care is climbing. The baby boom generation is aging into the Medicare population, and Americans are getting fatter. Both factors increase the need for care to manage diseases like hypertension and Type 2 diabetes.

And if health-care reform legislation, or Obamacare, survives Tuesday’s presidential election, more than 30 million adults could join the system once they gain coverage through private health insurance exchanges, their employers or Medicaid.

There aren’t enough providers — doctors or advanced practice nurses — to take care of all those people, experts said.

Asked how many additional nurse practitioners are needed, Peter McMenamin, senior policy fellow at the American Nurses Association in Silver Spring, Md., could only say, “More.”

In Ohio, there are about 6,200 nurse practitioners, according to data from the Ohio Board of Nursing. Nationally, estimates range from about 150,000 to 180,000 nurse practitioners, depending on the source, and about half are primary care providers.

“I don’t have a good number for how many more are needed,” he said. But, McMenamin added, federal data shows 59.1 million Americans live in medically under-served areas in both urban and rural communities. “There are a lot of potential patients out there who would benefit from having access to nurse practitioners,” he said.

Nurse practitioners have masters degrees in nursing, plus additional clinical training. They can diagnose and treat most chronic conditions, and can prescribe medications and order diagnostic tests. Depending on the state, they can specialize in a number of areas, including pediatrics, mental health, neonatal care, family medicine and adult acute or primary care.

Deb Rill has been a pediatric nurse practitioner for 25 years. She’s one of two nurse practitioners and 13 pediatricians who work at Pediatric Associates of Dayton. “When I was in high school in the 70s, nurse practitioner was a new concept,” she said. “I always knew I wanted to be a nurse. My mom read an article in the newspaper and sent away for a book about nurse practitioners, and that was it.”

She was a registered nurse for five years, working with newborn babies. Then she went back to school.

Now, she sees some patients every day who are coming in on “sick” visits for ear infections or the flu. Some she sees because their regular provider isn’t available. But most of the children she sees are her “regulars,” Rill said. “I’m their primary caregiver, and they choose to me to me for all their care,” she said.

For the last several years, the number of medical students and residents choosing to go into primary care — specialties that include family practice, internal medicine and pediatrics — has declined. Pay has a lot to with that decline, experts say. The salary gap between a primary care physician and specialist like a cardiologist or urologist can top $100,000 a year because health insurance companies reimburse less for primary care services than for specialty services.

The new health-care reform law mandates some increases in reimbursements for primary care providers to encourage doctors to accept more Medicaid patients expected to enter the system in states that accept additional federal funding to expand the insurance program.

As the number of primary care doctors declines, the number of nurse practitioners is increasing. In 2013, an estimated 11,000 new nurse practitioners will complete their training and get licensed, and a similar number is expected to enter the field in 2014, said Tay Kopanos, director of health policy, state government affairs, for the American Academy of Nurse Practitioners in Austin, Texas.

That sounds like a lot, but nationally, more than 67,000 qualified applicants were turned away from all levels of nursing programs nationally in 2010 because there weren’t enough instructors or other resources, said Mary E. Kerr, dean of the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland and former deputy director of the National Institute for Nursing Research, part of the National Institutes of Health.

“We’re educating nurse practitioners, but there are barriers,” said Christine Colella, who directs the nurse practitioner programs at the University of Cincinnati’s College of Nursing.

The main issue is a lack of faculty, both for registered nurses and advanced practice nurses. “It’s an aging group of people. And my students make way more money than I do,” Colella said. “It’s very hard to entice people to come into academia when the salary isn’t as good as if you were working as a nurse-practitioner.”

The health-care reform law includes funding to increase education capacity for nurse practitioners and other providers as one measure to increase the number of primary care practitioners.

Giving nurse practitioners more authority would let them see more patients, the profession argues.

But some physician groups, including the American Academy of Family Physicians and its Ohio affiliate, argue nurse practitioners don’t have the training to safely care for patients without physician supervision.

Nurse practitioners undergo 5,350 hours of education and clinical training, according to the AAFP. Family doctors complete more than 21,000 hours of training.

That training means doctors are better able to distinguish when a sore throat and fever are due to something mundane like the flu or when it’s something more dangerous, such as as human granulocytic ehrlichiosis, a rare tickborne infection that can be fatal, said Dr. Ratna Palakodeti, a Beavercreek family physician and president of the Ohio Academy of Family Physicians.

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