What brought this to my attention was the discussion in Colorado recently where the Governor, Bill Ritter, was trying to decide whether or not to opt out of the Medicare guidelines, which requires nurse anesthetists to work under the supervision of a physician. In 2001, the Centers for Medicare and Medicaid Services (CMS) instituted a rule in the Federal Registry that permits a state to be exempt from Medicare’s physician supervision requirement for nurse anesthetists with approval by the state governor. So far, 15 states have opted out of the federal requirement, instituting their own state requirements instead.

I’m not questioning the competency of the nurse anesthetist’s abilities to administer anesthesia within the scope of their practice. Nurse anesthetists are licensed to practice independently in each of the 50 states, though the scope of practice does vary from state to state. My point is: Now that the government will be footing the more of the healthcare bill in this country, there will be more procedures allowed by non-physician providers, to try to contain medical costs. This effort will have its affect on physicians and patients both, and neither of them positively.

For physicians it will cut into the income levels by allowing lesser qualified medical personal to make medical decisions that have previously been permitted only by licensed physicians. The argument that will be used by the government will be that many rural and inner city hospitals have difficulty recruiting doctors and specialists to adequately serve the medical needs of the area population. By allowing nurses and technicians to perform certain routine medical procedures, the public will have access to more medical treatment, and the public will benefit. I have no problem with this logic, up to a point. While routine procedures and treatments can safely be performed by aids, nurses, or technicians, the person best qualified to make medical decisions is still the doctor. Medical Doctors are the only members of the medical team qualified and licensed to diagnose. If, and when, non-qualified personnel are allowed to diagnose and initiate treatment protocols, then the likelihood of increased problems will occur.

For patients who are not examined by physicians, but are diagnosed and treated by non-physicians, the quality of care may not be the quality of care that they have come to expect. In most instances the diagnosis and treatment may be straight forward, but in the occasional case where the diagnosis is not so straight forward, or the treatment is not typical, the patient care will suffer. Patient care will suffer if the scope of practice for non-physicians is expanded without requiring increased educational criteria. There is a reason why all 50 states require doctors to be licensed, and that reason is to ensure quality patient care. The patient will certainly care who treats them, if they are misdiagnosed or mistreated by a non-physician. If the patient is not allowed to be examined or treated by a medical doctor due to budgetary constraints, then who is liable for any malpractice, if any occurs? The doctor, who didn’t examine and treat the patient, because this has been ‘usual and customary’ or the non-physician who examined and misdiagnosed the patient? Will malpractice insurance decrease for the doctor, because they are not treating as many patients, or will it increase because the doctor is liable for the actions of their staff?

When healthcare gets rationed because of the healthcare reform bill, where will the liability fall as patient care decreases, yet patient expectations become greater, because of the promises made by the politicians during the healthcare debate? As a physician in private practice you need to be aware of the assaults coming at you from all sides. In today’s political climate; only the greedy insurance companies are a bigger villain than the greedy doctors in the healthcare field.

Just trying to keep you informed on all the attacks that the private practice physician will be facing in the coming years.

Submitted by Dr. DG Comfort, CO

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5 Comments
#1 by Nicholas Tsambassis, M.D. on September 24th, 2010

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Dr.Comfort’s concerns echo my own and those of many of my colleagues and professional brethren regarding the projected expansion of the role of midlevel providers in primary care. Insurers, especially managed care plans, have promoted the myth that such providers are interchangeable with physicians, which they are not, no matter how competent or knowledgeable they may be. Obamacare seems to be very much attuned to the managed care mindset, which will perpetuate this approach. We in primary care need to do what we can to preserve the integrity of our profession and resist the encroachment of the nanny state.
#2 by Carri on September 27th, 2010

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I am relatively new to the healthcare industry but as a patient, will I be able to choose who I’d like to see? (i.e. Physicians vs. non physicians)
Also, will those non-physicians be expected to diagnose more than just colds or flu’s? Will they be expected to interpret your lab results and treat for whatever?
#3 by Chris Carraway, DC DIBCN on September 28th, 2010

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This exact same thing has been going on in the psychiatric world for over 10 years. A higly trained psychiatrist makes the diagnosis and the patient is turned over to a psychiatric nurse to manage the case with maybe a recheck by the psychiatrist later in the course.

Things are going to get worse before they get better.
#4 by Shawn on October 1st, 2010

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You raise a legitimate concern. However, I respect the President’s attempt to provide health care to all Americans and I believe that all Americans have a right to health care. I am the wife of a primary care physician and have had the opportunity (misfortune) to manage his office for 3 years. In that time, I learned first hand the insurance company’s greed, dis-concern for patients and complete and utter disrespect and outright theft of premiums from PCPs. Frankly, I believe PCPs should discontinue accepting insurance. This will allow patients to receive the level of care they deserve without insurance companies dictating their care and diagnosis. Further, PCPs can earn a respectable salary and can recoup the cost of med school. The cost of a med school education for PCPs is outrageous and the return on it is disgraceful. It’s bad enough PCPs are not sufficiently compensated but worse that they can’t pay off their med school debt. And for what, to get a slap in the face and told that someone with half their education and debt is on par with them and receiving close to the same salary?! It is disgusting how little respect they get from their colleagues who are well compensated and rely on them for referrals. It is disgusting how much the CEOs of insurance companies, hospitals, etc. get for my husband’s dedication and selflessness. I regret daily supporting my husband’s decision to become a PCP. He loves what he does and he’s an awesome doctor but we had no debt prior to this career change. We are getting the royal short end of the stick so any changes are neither here nor there to me.
#5 by Darrell on November 18th, 2010

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Being a Practice Manager in Primary Care, my first thought is to get the specialists to band together and refuse all referrals from mid-level practitioners. We need to ensure that the primary care physicians see these patient’s prior to the specialist accepting a referral. And, if this new reform does push the mid-level to the forefront, will the congressional powers-that-be stop requiring a supervising physician? Because, if they still require a supervising physician, then lets band together and have the physicians stop supervising them. No supervisor-no work for them!