When the Patient Protection and Affordable Care Act is fully implemented, it is estimated that more than 2 million Californians will gain access to health coverage. One important question facing our state as we implement this groundbreaking legislation is how to effectively care for these newly insured individuals. While some argue for increased training and residency slots for physicians, allied health professionals have used the guise of the act as an opportunity to increase their scope of practice.
Allied health professionals, like nurse practitioners, have sought to expand their ability to treat patients without physician oversight for years. As we begin to expand the network of care for Californians, these paraprofessionals are trying to capitalize and expand their practices without meeting the requirements that make health care providers accountable. Most recently, state Sen. Ed Hernandez introduced a trio of bills — SB 491, 492 and 493 — that would allow paraprofessionals to provide primary care services, including the prescribing of dangerous opioid narcotics, without the supervision of a physician. Supporters of scope expansion claim it will ease the provider shortage by allowing less trained allied professionals to take the place of physicians. But at what cost?
Under Hernandez's legislative proposal, health professionals such as nurse practitioners, pharmacists and optometrists would be able to administer and prescribe drugs, including highly addictive and complicated opioid medication. SB 491 alone would increase the number of prescribers of opioids like oxycodone by 14,000 with no additional oversights, protocols or investigative capacity. As California struggles with an alarming rise in prescription drug abuse, now is not the time to ease restrictions on who can prescribe these highly addictive and potentially fatal substances.
In addition to increasing the number of prescribers, these bills reduce the threshold for prescribing to include paraprofessionals with far less training and experience than physicians. California's licensed physicians are required to have four years of medical school and up to seven years of additional residency and training. On the other hand, most nurse practitioners have received the same amount of education as a second-year medical student. With tens of thousands of hours of training and experience, physicians are better able to prevent and recognize prescription drug abuse. Also, the type of training a physician and nurse practitioner have varies dramatically.
Proponents of these bills claim that they will ease the provider shortage by allowing allied professionals to treat individuals in underserved areas. However, there is little evidence supporting this claim. In states like Arizona where nurse practitioners are allowed to practice independently, there has not been a shift to rural or undeserved areas — in fact, they've stayed right where the physicians are practicing. So the claim that SB 491 will alleviate the physician shortage in rural California is simply not true.
The majority of nurse practitioners, optometrists and pharmacists are practicing in the same regions as physicians — not in the areas with a shortage of providers. Medical professionals are unlikely to relocate to parts of the state that lack access simply because their scope of practice is being expanded.
Lowering the threshold of accountability for primary care providers will not improve the status of our health care system; it will hamper it with new, unforeseen complications. It is imperative that those delivering patient care be highly trained, skilled and working as part of an integrated team.
Allowing paraprofessionals with a fraction of the training of physicians to prescribe dangerous substances and practice without oversight or protocols is irresponsible, and it threatens not only the integrity of our health care system, but patient safety.
Dr. Lawrence Cheung, M.D., is the president-elect of the San Francisco Medical Society. Dr. Stuart A. Bussey, M.D., J.D., is the president of the Union of American Physicians and Dentists.