ANNAPOLIS – Doctors are battling to keep their title as primary care physicians, while specialists and nurse practitioners plead with state legislators to give them more direct access to managed care patients.
Specialists say they have the expertise, resources and time to give patients the medical attention they deserve. Nurse practitioners reason they already have primary care provider status for Medicare and Medicaid recipients and should have the same role for managed care patients.
Physicians, meanwhile, admit there are certain circumstances when specialists should have direct access to patients, but say there is no reason to give such a privilege to nurse practitioners.
Specialists, too, don’t want to share patients with the nurses.
Physicians deny it’s just a battle for turf.
“I don’t think it’s a turf war at all, but a question of quality,” said Dr. Robert Lyles, an anesthesiologist and legislative committee chair for MedChi, Maryland’s physician organization.
“We have looked at this from the point of view of what is best for the patient. Patients should have access to the proper person at the proper time.”
In the physician’s view, Lyles said, specialists should have direct access to patients only during certain circumstances, such as when the patient has a chronic or debilitating illness that goes beyond the scope of a primary care physician’s practice.
But Dr. Donald Dembow, a Baltimore cardiologist, believes that managed care patients should have direct access to specialists regardless of their condition.
“The specialist can spend as much time as the patient requires, and we have access to rapid advances in the field, which we can then provide to the patient,” he said. “Primary care physicians have limited time to spend with patients and use a shotgun approach to situations. Under those circumstances, quality has to suffer.”
Putting patients directly in the hands of nurse practitioners, said Lyles, may not be in their best interest.
“My concern is that patients would be underdiagnosed because nurse practitioners don’t have the vast training that physicians” are required to have, he said. “You need this type of background to address the complexities of diagnosis.”
In Maryland, nurse practitioners must be registered nurses and complete a certified program; most have master’s degrees. To practice, nurse practitioners must enter into a collaborative agreement – which outlines their delegated medical functions – with a licensed Maryland physician. They are allowed to diagnose, treat, prescribe drugs, order X-rays and laboratory tests and make referrals to specialists. However, when difficult medical conditions arise, nurse practitioners consult with physicians, according to the state Board of Nursing.
Nurse practitioners say they don’t want to change their scope of practice – they only want equity for themselves and for managed care patients. This year, they backed legislation that would allow them to be listed on health maintenance organization’s provider panels, so patients can choose whom to go to for primary care. The House version of the bill was sent by its Environmental Matters Committee to interim summer study for further investigation; the Senate version is expected to follow.
“There are people out there who would prefer to see a nurse practitioner. We want people to have a choice and want to be recognized for what we do,” said Patricia Pappa, president of the Nurse Practitioner Association of Maryland. “I think there are fears that there will be direct competition with doctors. This can’t happen because there are 1,200 nurse practitioners and more than 10,000 physicians in this state.”
Carol Whittington-Washington, a nurse practitioner with her own private practice in Cheverly, said direct access would give patients a choice and still provide them with coverage.
Of Whittington-Washington’s nearly 800 clients, 90 percent are Medicaid recipients.
However, as many move from welfare to work, they lose their Medicaid benefits and the right to see her as their primary care provider. But instead of going to a doctor, many stay with her and pay for the care on their own, she said.
“There are children I’ve cared for since they were three days old and just because their parents got a job, I can’t see them anymore? That bothers me,” she said. “It hurts me to have to take cash from patients because my clients scrape for this care.”
One patient, she recalled, paid her in $1 bills – the money he received from his job as a stripper. She also works out payment schedules for those who can’t pay the full sum. For those who don’t have transportation, she makes home visits. Whittington-Washington remains optimistic that physicians and legislators can reach a compromise. “We are not doctors. We don’t claim to be, and we’re not trying to be. We want to care and help others to care for themselves,” she said. “Sometimes people don’t just want to get a prescription and walk out the door. They want someone who will listen. They want that caring aspect.”