|August 30, 2002
Donald S. Clark
Re: Comments Regarding Competition Law and Policy & Health Care
I would like to suggest that to encourage innovation, efficient delivery and cost-effectiveness in health care, the Commission make every effort to level the playing field among health care providers. There are a multitude of statutory, regulatory and policy barriers which are left over from the 1950s, are unnecessary and have no usefulness other than to anoint one class of health care providers over others. The anointed providers -- usually physicians -- use those policies to keep other types of clinicians out of the market.
Other types of clinicians -- nurse practitioners, for example -- are specifically authorized by state law to diagnose illnesses, form a treatment plan, order diagnostic tests, interpret the results, prescribe medication and follow up. Some nurse practitioners have admitting privileges at hospitals. Physician assistants, nurse midwives, clinical psychologists, and, in some states, pharmacists also have the legal authority to diagnose and treat.
Nurse practitioners are diagnosing, treating and providing long-term follow up of patients in medical practices, in schools, in nursing homes, in patients' homes, in hospices, in rehabilitation facilities and in hospitals.
The federal law on nursing homes contains several provisions which require a medical doctor's "direction," of the care of nursing home patients. This is unnecessarily duplicative of what the nurse practitioners provide. There is no scientific or policy reason why a nurse practitioner could not perform the medical director's duties. Furthermore, Federal law on hospice requires a physician as medical director, Federal law on home care requires a physician order, and federal law governing hospitals require the care to be under the direction of a physician. All of these laws which carve out a place for medical doctors are left over from the 1950's or 60's when, in fact, medical doctors were the only clinicians who had the legal authority to diagnose and treat.
The American Medical Association and its state affiliates spend much effort and verbiage defending the turf of medical doctors. They attack any policy change, regulatory change or statutory change which attempts to level the playing field. Worse, these "medical directors" make sure that a) only physicians can be admitted to managed care provider panels, b) only physicians get hospital admitting privileges and c) only physicians get on the policy-making committees.
Here is what some health policy experts suggest:
"Create -- then embrace -- a system where the clinician's skill level is matched to the difficulty of the medical problem....Rather than try to fight the nurse practitioners who are invading their turf, primary care physicians should move up market themselves, using advances in diagnostic and therapeutic technologies to perform many of the services they now refer to costly hospitals and specialists...." Christensen, C.M., Bohmer, R. and Kenagy, J. "Will Disruptive Innovations Cure Health Care?" Harvard Business Review, September-October 2000, p. 102-112
"The first tier -- the front line of delivery -- should be the non-physician practitioners: physician assistants, nurse practitioners, and certified nurse midwives. These professionals are capable, reliable and cost-efficient." J.A. Califano, Jr., Radical Surgery:What's Next for America's Health Care. Times Books, 1994. p. 217.
"Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care." Harrocks, S., Anderson, E, and Salisbury, C. "Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors," British Medical Journal,324: 819-823 (2002).
What can the FTC do?
1. Investigate complaints from nurse practitioners and other clinicians about restraint of trade by physician groups.
2. If a panel, commission, task force or committee calls for a medical expert, consider appointing nurse practitioners.
3. Evaluate the wording of policies, regulations, and proposed statutes so that all classes of clinicians who are legally authorized to perform medical services are named -- not just "physicians" and not just "physicians and others authorized."