Opinion: Daily Journal

Practice A New Approach

RALEIGH – With Medicare about to start running huge fiscal deficits, and the long-term-care portion of Medicaid presenting the program’s biggest fiscal challenge to states such as North Carolina, it’s critical that policymakers carefully consider more-efficient ways to deliver services to the elderly and disabled.

One promising idea, according to Business Week, is making greater use of nurse practitioners. Because they aren’t MDs, NPs are less expensive to train and deploy. Of course, they are also trained to nurse (to manage symptoms and alleviate suffering) rather than to doctor (to diagnose and treat, perhaps to cure). But in the particular context we are talking about – geriatric medicine and the treatment of those with severe, long-term physical or mental disabilities – the nursing model is spot-on.

The magazine told the story of Evercare, a division of UnitedHealth Group that coordinate care for the company’s elderly clients. It has pioneered the extensive use of NPs to improve its services efficiently, and the results seem impressive. “We know that investing in an NP up front leads to better care and a lower cost at the back end,” Evercare’s CEO, Dr. John Mach, told Business Week. “We’ve achieved a 45 percent reduction in hospitalizations with no negative impact.”

Too good to be true? Maybe. It has been my experience that whenever issues involving competing occupational classes come up – docs vs. nurses, optometrists vs. opthamologists, even barbers vs. cosmetologists – the lobbying groups tend to make big claims and issue sweeping generalizations. Naturally, the truth usually lies somewhere in between the competing poles. The problem is that governments too often force it. They gravitate towards one pole or the other, picking the “winner” in fights over occupational licensure or access to public dollars on the basis of first impressions, personal connections, or (ever heard of this before?) who supplies the most campaign cash via bathroom delivery.

In the case of NPs and government health programs, it seems to me that the best way to determine the optimal mix of MD and non-MD providers is to encourage competition among private provider networks to deliver the tax-funded service. This can be done by offering capitated amounts fixed in value according to the patient’s health status – though that’s much easier said than done – and then, critically, allowing patients the ability to choose the providers on the basis of service quality, price, and customer satisfaction. If the policy is simply to make as many Medicare and Medicaid patients as possible into lower-cost alternatives, I’m certain that the result in more than a few cases will be inadequate care. Of course, inadequate care happens now and will happen under any system. The relevant questions really involve who gets to decide what “inadequate” means, and what recourse to patients have if their system they are in doesn’t meet their needs.

I know from previous columns on such topics that I’ll get emails from doctors warning me of the dangers of unsupervised nurse practitioners, and from NPs arguing for far-strongest movements in their direction, and from other nursing professionals making their own case. Here’s the point: I recognize there are competing claims, costs and benefits to be weighed. I also recognize that most people outside of these fields can have trouble evaluating these competing claims because they lack the necessary expertise or information. But I also know that the history of occupational lobbying and licensure is not a pristine one, and that no small amount of small pleading and rent-seeking has gone into the formation of public policy benefiting or hurting particular groups.

Basically, don’t kid a kidder. There is no right or wrong answer to these kinds of questions. There is only a rough approximation of the right mix, arrived at as a consequence of millions of free individuals making good-faith choices, competing for scarce resources and cooperating to put them to their best use to pursue common interests, and then finding out what works best for them.

You know, a market.

Hood is president of the John Locke Foundation.