Non-physician practitioners to assume larger role.

Nurses, doctors' assistants fill primary-care functions

As the nation moves toward a health care system dominated by managed care, the need for primary-care physicians is becoming greater than ever. Yet the ongoing shortage of primary-care physicians does not appear to be abating. As a result, an increasing number of practitioners who are not M.D.s - particularly nurse practitioners and physician assistans - are stepping forward to fill the primary-care gap.

The relatively low earning capacity and prestige of general practitioners have severely curtailed the number of medical school graduates going into primary care. Specialists, such as surgeons, typically earn up to twice as much as general practitioners, according to several medical experts.

Experts also stressed that specialists typically have more-exciting jobs, which is another factor contributing to the chronic shortage of primary-care physicians.

Under most managed care systems, primary-care physicians act as the gatekeepers to patients seeking treatment from medical specialists. A patinet can only see a specialist if he or she obtains a referral from a general practitioner, family physician, pediatrician or other primary-care provider.

As Dr. John Harris of Blue Corss of California explained, people's habits are changing. In the past, many made a habit of immediately visiting a specialist for a specific problem. Often, however, the problem is a simple one that can be easily diagnosed and treated by a generalist.

The problem with immediately seeing a specialist is that specialists typically charge much more than generalists, explained Harris. Under managed care, most patients visit their primary-care physicians much more regularly than they would under a pay-for-fee system, which is why managed care systems help keep the cost of health care down.

Despite managed care systems' greater use of primary-care physicians, many providers operating under such systems contract with far more specialists than generalists. For example, Blue Cross, one of Los Angeles County's largest health maintenance organizations, contracts with many more specialists than primary-care physicians. According to Blue Cross spokesman Michael Chee, Blue Cross contracts with 22,000 specialists, but only 13,000 primary-care physicians.

So the question remains: Who will pick up the slack in primary care in the future? One answer seem to be that nurse practitioners and physician assistants will likely play larger roles as primary-care givers.

Nurse practitioners are registered nurses who have gotten extra training. Physician assistants are health care providers who have successfully completed a two-year course in basic medicine.

Several local HMOs - such as Kaiser Permanente, FHP Health Care and Blue Cross - have already started employing more non-M.D. practitioners to help lighten the load on primary-care physicians. FHP spokeswoman Diana Mann stated that, although "mid-level professional," as FHP calls nurse practitioners and physician assistants, are not replacing doctors outright, using them as allowed primary-care physicians to server more patients.

In addition, California nurse practitioners and physician assistants are lobbying to get prescription-writing privileges, which would enhance their position vis-a-vis general practitioners even more.

In the dawning ere of managed care, controlling costs is quickly becoming a top priority. So, using non-M.D. practitioners for primary care has become not only necessary, but also attractive because it is cost-effective.

Dr. Jeffrey Klein, a family physician with Kaiser Permanente's department of family practice, stated that nurse practitioners with Kaiser "see a lot of routine illnesses." Kaiser tries to limit their use of nurse practitioners because, as Klein put it, "a lot of patients expect to see their physicians."

Dr. Harris of Blue Cross said that nurse practitioners serve as a "quick fix" at that HMO when no physicians are available. They are also employed at Blue Cross for situations in which they can do an equally effective job as physicians, but in a more cost-efficient manner. "A well-run, efficient system probably does benefit from having some practitioners as part of the team," said Harris.

In the long run, however, Harris said he doubts practitioners will play a larger part in administering primary care. He predicted that specialists, rather than practitioners, will be brought in to fill the gap in primary care.

Medical schools will likely to start retraining specialists to become generalists, said Harris. Another possibility is that specialists may simply begin practicing primary care on their own.

Harris pointed out that specialist are definitely qualified to administer primary care, given their extensive education and medical training. "The government will not tell a cardiologist that he cannot treat a head cold," said Harris.

Kaiser has developed its own formula for staving off a primary-care shortage. It launched on June 28 a Family Medicine Residency Program at Kaiser Permanente Medical Center in Woodland Hills, dedicated to training primary-care physicians. About half the medical center's residents are expected to continue on at Kaiser Permanente after completing their residencies.