Thousands of elderly patients lost their health care provider, and nurse practitioner Michelle Schmerge had to watch them go.
When her supervising physician decided to retire, she couldn’t find a replacement. As a nurse practitioner in North Carolina, Schmerge couldn’t practice without a doctor’s guidance, but geriatric doctors are in short supply.
Patients with dementia, frailty, and a host of other medical issues suffer the consequences.
That’s why Schmerge now supports Senate Bill 143, the SAVE Act, which was introduced in the General Assembly in 2019. The bill would lift state requirements that force advanced nurse practitioners — like Schmerge — to operate under physician supervision. If passed, the bill would allow Schmerge to keep her patients, she told Carolina Journal.
Supporters of the SAVE Act plan to move on the bill this year, potentially as soon as this month, said Rep. Gale Adcock, D-Wake. The bill has bipartisan support, and its sponsors include chairs of the health committees in the House and Senate.
As Baby Boomers age, they are living longer. But many have chronic diseases, and are aging into a health care system that isn’t ready for them. While patients suffer, taxpayers and private insurers stoop under an ever-worsening burden.
Schmerge argues that nurse practitioners could fill in the gaps — if they didn’t have to pay thousands of dollars for supervision. Like other nurse practitioners, she says that physician oversight is often limited to a few signatures and two visits per year. But S.B. 143 faces serious pushback from physician organizations that argue geriatric care will atrophy unless education and payments are changed.
Similar reforms flopped in California after lobbyists for doctors waged a bitter campaign against freeing nurses from physician supervision. They drummed up fears for patient safety, which nurses characterized as a blatant disguise for physicians’ desire to keep collecting money from nurses.
In 10 years, one in five Americans will be eligible for Medicare. In North Carolina, the number of adults 65 and older will almost double in the next two decades, jumping to 2.6 million.
“We are going to have an explosion of patients with neurodegenerative conditions that are not currently curable,” said Dr. Chrissy Kistler, associate professor at the UNC School of Medicine. “How do we address that? How do we come to terms with it? These are our moms, our dads, our grandparents — how do we help provide them care?”
The nation will need 36,000 geriatricians by 2030, but won’t have half that many, predicts the National Academy of Medicine, a nonprofit research organization based in Washington, D.C.
Geriatrics isn’t a popular profession. It doesn’t pay well — geriatricians earn less than half of an average cardiologist’s salary — and it struggles to attract medical students. Only 35 of the country’s 139 geriatric fellowship programs were filled in 2018, according to the National Resident Matching Program.
“It’s one of the few specialties that you get extra training to make less money,” Kistler said. “And who wants to go into that sort of specialty?”
But without geriatricians, the frailest patients — many of whom take a cocktail of prescriptions and face complications from the simplest surgeries — are left to navigate the tangled health care system alone.
“I don’t think it’s because primary care doctors are bad,” Kistler said. “But 20 minutes in the doctor’s office doesn’t work when you have a list of medications that is 20 meds long. … Our system is poorly designed to meet the demands of this population.”
Nurse practitioners like Schmerge say they could help meet patient demand if North Carolina lifted cumbersome regulations. They have won full practice authority in 22 states. If passed in North Carolina, S.B. 143 could be added to their list of victories.
“The sandbox is so big that we should all get in there to do whatever we can to care for these people,” Schmerge said. “But there just are so few physicians that practice in this space. Everyone is trying to figure out how to get out of it. It’s a hard, hard world.”
The consequences of shortages will be enormous. A fourth of all Medicare spending already goes to people in their last year of life, states research from the National Institutes of Health. Delays in care lead to spikes in spending.
“Accessibility, especially in aging, is critical,” Schmerge said. “Within hours, a patient who hasn’t eaten and is vomiting will go from fairly functional to incredibly [deteriorated] and needing hospitalization. Accessibility is critical.”
The American Medical Association opposes the SAVE Act, citing concerns for patient safety. New nurse practitioners can have 13,500 fewer hours of clinical experience than a family physician, according to the American Academy of Family Physicians, one of the nation’s largest medical organizations that opposes expanding scope of practice laws. Some physicians also fear hospital systems will replace them with advanced practice nurses to cut costs.
“Their training, in my experience, has been widely variable,” said Dr. Darlyne Menscer, AMA state delegate. “The relationships with supervising physicians are important because it assures us that these variably trained people really are capable.”
A host of studies disagree, including a report by the National Academy of Medicine. But much of the literature is dominated by bickering between physician organizations, nurses, and academics.
“This is a very bad return on investment for our country,” said Susan Hassmiller, a senior adviser at the Robert Wood Johnson Foundation, a national provider of health care research and education grants. “Everyone should practice to the top of their education and training because that’s the only way to get people the care they deserve.”