Herrick: Future Pandemics Require Better Access to Primary Care

When Americans become ill or have a health complaint, they often schedule an appointment with a primary care provider (PCP). PCPs are often the first line of defense in the battle against the onset of seasonal outbreaks of colds, flu or more serious problems like COVID-19.

Nearly 1 million COVID-19 cases have been confirmed across the United States, of which more than 50,000 Americans have died. Estimates vary but perhaps up to half of those exposed to COVID-19 exhibit few if any symptoms. Maybe one-in-ten need hospitalization, while about two-to-five percent (depending on the region) succumb to the virus.

What characterizes those who’ve died from those who recover is often pre-existing health conditions that rendered them less able to overcome the virus. It turns out many of the chronic conditions that are slowly killing Americans are the same comorbidities killing them from COVID-19.

Some of the chronic conditions that are associated with a greater likelihood of death include advanced age, obesity, diabetes, hypertension, heart disease, and chronic lung disease. This suggests the best way to save people from future pandemics is to start years earlier with better access to primary care providers, who can help them better manage chronic conditions.

The COVID-19 pandemic has brought to light the barriers many Americans face when they need quick access to primary care. During cold and flu season, a call to your doctor is often met with an appointment time slot that is days if not a week or more away. Physician appointments a week after becoming ill also do little to alert public health officials of outbreaks of flu, colds or a pandemic.

Many of the most vulnerable Americans need better access to a PCP who knows their medical history. The problem is that too few PCPs exist to treat patients. According to the Centers for Disease Control and Prevention (CDC), there are approximately 46 PCPs per 100,000 population on average across the United States. In this case, the CDC definition of PCPs is limited to those in general and family practice, internal medicine, geriatrics and pediatricians. Of course, some areas have more PCPs than others. Large metro areas have more than rural areas, while large coastal cities have more than flyover country. Why? It probably has something to do with money. According to Medscape, specialist physicians earn about $100,000 per year more than physicians practicing primary care. Indeed, the highest-paid specialties earn more than double what primary care and public health physicians earn. Thus, it is no wonder why medical school graduates were moving away from practicing primary care.

How do we make more people want to practice primary care and increase the number of PCPs caring for Americans? The solution is simple, but contentious. There are already approximately 400,000 nurse practitioners (NPs) and physicians’ assistants (PAs) in the United States. Thousands more graduate every year. Many of these already work in primary care but lack the authority to practice without strict physician oversight. If the state scope of practice regulations were expanded to allow more autonomy, the field would grow even more.

NPs and PAs are medical professionals uniquely qualified to help those struggling to manage chronic conditions. Yet, state medical boards, state medical societies and state legislators often fight tooth and nail to limit efforts to expand what NPs and PAs are allowed to do. The American Medical Association actually boasts that “AMA successfully fought scope of practice expansions that threaten patient safety.”

The argument physicians often use goes something like this, “It’s a bad idea. I once had a patient who was misdiagnosed by a NP.” I suspect it has more to do with turf battles. Physicians struggled mightily to attain their revered status as physicians. They are loath to surrender turf that is their exclusive domain. That’s understandable, but it’s also unacceptable. It is not a good reason to deny Americans the choice to see an NP or PA if they choose.

Just under half of states grant NPs and PAs full practice authority. One-third of states allow some form of reduced practice, requiring career-long collaboration agreements with physicians. About one-quarter of states require a more rigid form of supervision or delegation of authority to practice medicine under physicians. Some states like Texas even limit the number of NPs any one licensed physician is allowed to supervise. For example, a Texas physician can supervise no more than four NPs, who must practice within 75 miles of that physician. That means a doctor in Dallas cannot supervise a NP caring for patients 400 miles away in small-town, Perryton Texas (population 8,600).

Americans are aging. About 78 million Baby Boomers have retired or are about to, and all will become Medicare eligible over the next few nine years. This huge cohort will boost the need for primary care. Millions of younger Americans lack a relationship with a PCP. The best way to improve Americans’ health and prepare for the next pandemic is to expand who can legally care for patients and expand their authority to practice.

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