Taking Advantage of Disaster: Reinventing vs. Restoring

If I’ve learned one thing for sure from 50 years as a health economist, it’s that identifying a problem does not soon lead to solving it.  Thanks to monopoly power and political rigidity, inefficiencies in the medical marketplace persist long after they are revealed, and responsive “health reforms” don’t generally improve the system-wide allocation of resources or methods of production.  A French truism captures this American reality: the more things change, the more they stay the same.

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The inertia of tradition is a major disappointment for those of us who studied economics in college in the sixties.  We believed back then that enlightened inquiry would make the world a better place and that economic policy would eliminate market failures by respecting the lessons of history.  However, it wasn’t long before we realized that political decisions are not based on rational economics and that progress is incremental at best.  Resistance to change is the paradox of American exceptionalism.  Creative destruction can lead us forward, but very slowly under normal circumstances.  Only a major disaster (e.g., war, revolution, earthquake) seem to produce significant changes in relatively short periods of time. 

Like a city ravaged by a hurricane, it will need to be rebuilt. 

What does my consternation here have to do with this column’s usual focus, the future of nurse practitioners?  Well, the coronavirus pandemic is a major disaster.  The health care delivery system will not be in any position to return to normal once it has passed.  Like a city ravaged by a hurricane, it will need to be rebuilt.  Covid-19 may therefore be just what we need to make changes suppressed by monopoly and politics.  However, progress will occur only if reinventing health care is the explicit goal of recovery—something completely different from restoring it to the way it worked before the pandemic.  

Elevating advanced practitioners to full scope-of-practice authority is indisputably an excellent solution for a major pre-pandemic problem—along with routinizing telemedicine, minimizing fee-for-service reimbursement, restoring public health, and integrating mental and physical care.  We must make these changes because the old (pre-2020) system wasted at least 30% of every dollar spent on health care.  So, do we want a better deal, or just the same mess for less?  How could we not want to implement solutions that are proven to improve efficiency and effectiveness?  I see it as imperative because the pandemic’s economic fallout will significantly reduce money available for medical care.    

The good news is that all evidence supporting direct access and full-practice authority for advanced practitioners is overwhelming and consistent.  My latest (2020) edition of Not What the Doctor Ordered contains hundreds of citations to peer-reviewed publications that demonstrate how advanced practitioners are at least as efficient and effective as physicians within their defined scopes of practice.  Extensive literature searches conducted for me by two professional librarians didn’t find a single research-based article to the contrary.  Defenders of monopolistic practices in health care’s labor markets simply don’t have any science-based, peer-reviewed publications to support restoring the pre-pandemic hierarchy (i.e., physician supervision of advanced practitioners). 

The bad news is that monopolists fight hard to retain their dominance.  They will continue to barrage legislators and regulators with anecdotal scare tactics, not scientific studies.  Nurse practitioners must therefore make the case for change directly to consumers, employers, health plans, and others on the demand side of the marketplace.  The general public needs to be educated and energized to go directly to elected officials and bureaucrats and to forcefully demand an end to the medical monopoly.  Employees, employers, and retirees are the ones paying the high prices (i.e., unacceptable quality, non-competitive prices, uneven access) of pre-pandemic health care. 

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Public interest groups, civic clubs, business organizations, and both political parties need to lead a coordinated charge for change at our state capitals and government agencies—with extensive input from a coalition of advanced practitioners and the many physicians who support them.  Nurse practitioners are a particularly important resource for intensifying public pressure to shape post-pandemic policies for positive, long-overdue change.  As shown convincingly by the case studies in Not What the Doctor Ordered, some of our country’s most successful new approaches to health care were designed, implemented, and managed by nurse practitioners. 

However, creating public demand for systemic redesign as the foundation of disaster recovery isn’t enough to get the job done.  Most health care delivery organizations will continue to resist change because it is a losing proposition under the current reimbursement system.  In their defense, health system leaders who protect the status quo are usually making a rational economic decision to ensure organizational survival. They will gravitate toward changes that make things stay the same. 

Therefore, nurse practitioners and their collaborators must do more than make the well-documented case for reinventing health care.  They must also become equal members of the organizational teams that redesign delivery systems and work processes.  As the saying goes, “If you are not at the table, you are on the menu.”  Simply asking executives and physician leaders to take NPs’ ideas into account doesn’t work.  All available evidence shows advanced practitioners are as qualified as physicians to provide health care, so they are surely as qualified to be equal partners in redesigning the systems that make it available to patients.