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State doctor shortage diagnosis: critical but stabilizing

The patient is still in critical care, but his condition is stabilizing.

That’s the diagnosis on Nevada’s doctor shortage, a chronic problem that’s getting some first aid from state lawmakers, but that needs longer-term remedies to heal completely.

“I do think we’re making a dent in it, but I’m a little concerned that legislators might think just tweaking scope-of-practice laws or dealing with reciprocity (out-of-state licensing) will take care of the issue. It won’t,” said John Packham, a health policy researcher at the University of Nevada School of Medicine.

The legislative focus follows Packham’s February health workforce report, which revealed big, statewide doctor shortages. Those shortages are especially important because health experts say they’ll only worsen after January, once the Affordable Care Act — or Obamacare — puts hundreds of thousands more Nevadans on insurance rolls. Lawmakers do have solutions, and though some of them seem set to become law, observers agree the proposals aren’t enough.

To understand why, consider the numbers. Packham’s analysis showed the Silver State ranks 46th or worse in primary care doctors, family practitioners, pediatricians, psychiatrists and general surgeons per 100,000 residents. That low ratio could become a major issue as the number of insured rises, because people with coverage are likelier to see the doctor. Packham’s research found that primary-care visits in Nevada could surge by as many as 280,000 appointments a year post-Obamacare.

To handle the patient influx, legislators said in January that they’d work hard to boost provider counts. They’ve kept to that, introducing bills in a variety of areas. Senate Bill 324 would streamline Nevada medical licensing for doctors already licensed with unblemished records in other states. Dr. Mitchell Forman, dean and professor of medicine at Touro University Nevada College of Osteopathic Medicine in Henderson, said the bill would help quickly recruit doctors to the state by slashing license-approval times for relocating doctors from several months to a few weeks.

Other bills might not help as rapidly.

Forman said doctors are working with legislators to expand medical residencies in Nevada. Doctors typically practice within 70 miles of where they complete their residency, so it’s important to expand graduate medical education here, Forman said. Markets that could see the biggest gains are mostly underserved areas in rural parts of the state, and in urban cores. Residencies would also be outside the traditional hospital setting, happening in outpatient and community clinics, for example.

Finally, Assembly Bill 170 and Senate Bill 69 would expand scope of practice for advanced practice registered nurses, relaxing requirements on physician oversight and letting nurses handle more routine primary care independently.

But the problem with boosting medical residencies is that it’ll take more than one legislative session to find the money and rewrite the rules to fund them, Forman said. And the bills to let nurses practice primary care on their own face stiff opposition from doctors’ groups.

“It’s a very messy issue, and one of paternalism and control,” Forman said. “It’s being looked at as a turf war, or war of financial interests, and it’s really not. For most primary care issues, I think advanced practice nurses and physician assistants are very capable of performing, but I think it should be in the context of having a formal supervisory relationship with someone who has more training and experience. Ultimately, it’s about patient care and safety. You can’t get me to believe that an advanced practice nurse who’s had limited education in terms of time and experience is more competent than a physician who’s had considerably more education and residency experience.”

Still, Packham said he senses little legislative opposition to lifting some limits on advanced practice nurses. Nevada is one of the few remaining states with its level of restriction, and increasing the number of doctors alone won’t be enough to solve primary care shortages here.

“The training and pipeline issues are much smaller for nurses and physician assistants, and I think everybody knows that,” Packham said.

Yet, even if every health-related bill passed in the session, which ends in June, it wouldn’t be enough to fix shortages, observers agree.

State Sen. Joe Hardy, R-Boulder City, said Nevada must find funding for more medical residencies. Packham also cited the need for “substantial investments” in both undergraduate and graduate medical education, but that won’t be an easy task in a state where revenue is still reeling from half a decade of economic downturn. If Nevada can’t work its way through its residency shortages, today’s bills will mean little.

Said Forman: “The answer is developing innovative and creative ways of training our medical graduates in the state and keeping them here. Unless that dramatically changes, we’ll be having the same conversation about shortages 10 years from now.”

Contact reporter Jennifer Robison at jrobison@reviewjournal
.com or 702-380-4512. Follow @J_Robison1 on Twitter.

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