Nurse Practitioners and the Allocation of Resources

In my last post, I made a rather conclusory (and parenthetical) statement regarding the utilization of nurse practitioners in retail health clinics. I wrote:

Retail health clinics have sprouted up across America as of late. They can be found in grocery stores and pharmacies, are open nights and weekends, often (wisely) utilize the services of nurse practitioners for minor ailments and feature a clearly listed schedule of fees.

Today I’ll clarify. The view espoused is largely based upon simple resource allocation theory: that one utilizes resources effectively by matching the need with the skill; that to underutilize is to engage in waste, and, given demand and a shortage of doctors, when a physician is attending to minor ailments, and charging physician rates to do so, society has experienced a net loss.

The trick of course is in a) making sure that there is a sufficient supply of well trained nurses (you may wish to take a look at this interesting RWJF blog from Susan Hasmiller, “projected shortage of 500,000 nurses by 2020,” despite the present difficulty of some nurses to find work ); and b) assuring that the need of the client is matched with the appropriate level of skill: that the service provider is capable.

According to the Mayo Clinic, “NPs are registered nurses (RNs) who are prepared, through advanced education and clinical training, to provide preventive and acute health-care services to individuals of all ages. Today, most NPs complete graduate-level education that leads to a master’s degree. They work independently and collaboratively on the health-care team.”

As to the capability of nurse practitioners, this quote (n. 14) from William M. Sage, Out of the Box: The Future of Retail Medical Clinics, Harvard Law And Policy Review Online (2009), is worth noting:

Debate over the relative merits of primary care from nurse practitioners and from physicians is purely rhetorical. A review of 11 trials and 23 observational studies in primary care settings concluded that “[q]uality of care was in some ways better for nurse practitioner consultations.” Sue Horrocks et al., Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide Equivalent Care to Doctors, 324 BRIT. MED. J. 819, 819 (2002). See also Linda H. Aiken, Achieving an Interdisciplinary Workforce in Health Care, 348 NEW ENG. J. MED. 164 (2003) (editorial describing the quality of non-physician professionals); Mary O. Mundiger et al., Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial, 283 JAMA 59 (2000) (demonstrating equivalent outcomes).

Universal Health Insurance for America’s Children - Can It Happen?

by katchingkyleigh1 via flickr

It is no secret that America’s health care infrastructure leaves much to be desired.  It spends more on health care than any other country in the world, but is far from achieving the best results.  The extreme cost of care has contributed to increased rates of the un- and underinsured — climbing from 41.2 and 15.6 million in 2003 to  49.6 and 25.2 million, respectively, in 2007.

Most observers agree that the American health care system is badly broken–if it ever was intact–as evidenced by the large number of Americans without health insurance, the high and rising costs of health care, and the relatively poor health outcomes achieved for the money spent.

What might be lesser known is the degree to which lack of health coverage affects children.  In their article, Universal Health Insurance for Children, published in the Journal of Health Care for the Poor and Underserved, Hughes et al. note that despite programs designed to enhance children’s access to coverage like State Children’s Health Insurance Program (SCHIP), about 8.1 million children were a part of the uninsured population in 2007.  Confusion about eligibility is often cited as a reason many children — over 80% of low income uninsured children - who are eligible for coverage do not have it.

Children’s health insurance status helps predict whether they receive needed health care and provides a critical means for identifying and addressing their health problems early in life… Children  who experience unmet health problems are more likely to miss school, to incur high costs for medical care, and to have parents miss work due to caring for an ill child.

Consequences of non-coverage of children start with compromised access to health care and turn into compromises to the American economy.

Lack of insurance coverage for children not only has an immediate impact on those whose access to care is limited, but it also has social implications in terms of potential public health threats due to untreated communicable diseases, higher health care costs for end-stage treatment, and consequences for the economy in terms of productivity and high insurance costs to businesses.

It has been well documented that providing health insurance coverage is cheaper than paying for the consequences associated with the alternative, but America has been resistant to providing universal coverage.  Providing coverage specifically for children, on the other hand, has been met with less resistance.

The social and individual benefit of extending preventive care and health insurance to children, however, is somewhat less contentious [than providing insurance to adults], largely because children are viewed more sympathetically than adults by health care leaders and the American public.

Hughes et al. argue for immediate universal coverage for children, rather than waiting for universal coverage for the country as a whole and note that it would have to occur at the federal, as opposed to state and local, levels.  They make two recommendations for achieving this goal.

One option is to create a Medicare-like federal program under which all children are automatically enrolled in a comprehensive insurance program, regardless of income. By and large, Medicare works well for seniors and is a reasonable model for children. Another option involves modifying Medicaid, SCHIP, and other categorical programs to create a uniform insurance program for low-income and undocumented children that eliminates the confusion and complexity associated with multiple programs. Both options would require sufficient minimization of paperwork and reimbursement to providers to ensure that coverage translates into genuine access to care.

Hughes et al. point out that most Americans support universal coverage, especially for children, despite the added tax burden it may cause.  This is probably a sentiment reflecting the reality of the extreme cost and gross inefficiency of the American health care system.  As children constitute a categorically vulnerable population which affords them the sympathy of the country, it makes sense to begin the road to universal health care in this country with them.  The vast majority of taxpayers are willing to foot the bill and we have an administration ripened to bring about such a change.  If ever there was the time to begin the process of providing universal health insurance to children in America, it would be now.

Surprise, Surprise: Older Americans are Sicker than their European Counterparts

In this international study, we found that US adults of all wealth levels reported worse health than did Europeans at comparable wealth levels.  Poor Americans were at particularly worse health compared with their English or other European counterparts, but even well-off Americans reported health comparable to substantially poorer Europeans.  Differences in behavioral risk factors accounted for only a fraction of these disparities.

As behavioral factors were insufficient to account for this disparity, Avendano et al. distinguish between national health care systems.

Features of the US health care system may contribute to the worse health of Americans compared with Europeans.  In particular, most European countries have a stronger primary care orientation than does the United States.  Previous evidence suggests that a strong primary care system is associated with better health outcomes, partly because it entails a stronger focus on primary prevention, a more equitable distribution of resources, and a higher efficacy of the health system.

Investing less at the primary care stage where prevention is key, necessarily means that there is a greater focus on disease maintenance or amelioration after its onset.  Which is to say that Americans, for the most part, are not afforded significant medical attention until they are sick.

In addition to having a stronger focus on primary care than the United States, European countries have greater protections for their poor.  European countries offer virtually universal health care coverage, so even the poor have relatively unfettered access to necessary care.  The United States on the other hand, has an uninsured population totaling 41 million (or over 45 million by some estimates).

The fact that health disparities in England still persists despite access to care,

suggests that mechanisms outside the health care system may also be involved.  Wealth enhances access to material resources such as housing, and is a source of immediate consumption in periods of economic strain. Wealth may also increase sense of control over life and other psychosocial resources that can enhance health.

This study gives further credence to the notion that America has at least something to learn from the European health care system.  Universal health care is one component, but focusing more keenly on primary care and easing the social burdens of the poor are another.  Racial health disparities is also an issue that has to be addressed in the United States, but this study restricted its study population to non-Hispanic Whites in order to determine what factors beyond those attributable to race are at issue in the United States’ lag behind its European peers.  Given the fact that racial health disparities are prevalent in the United States, it would not strain reason to conclude that the gap between Americans and Europeans would be exacerbated if racial minorities were included.  The correlation between economic status, residential segregation and well being may help explain why this is the case.

The United States health care system clearly demonstrates that dollars spent is no indication of the quality or efficacy of health care actually received.  Moving into a more cost-effective health care  paradigm that provides access to comprehensive care at a stage where it can impact long-term health is essential.  The Avendano study offers proof of this.