I posted recently on John Goodman's and Virginia Traweek's post on nurse practitioners. There ensued on his site a lively debate among those who want to allow more room for NPs to practice and those who don't. Uwe Reinhardt, a fairly interventionist health economist from Princeton, weighed in on Goodman's side with two comments. Both were excellent. Parenthetically, one thing I appreciate about Uwe is his sense of humor.
Excerpt from Comment 1 (the whole comment is worth reading):
I would be inclined to say that I fully agree with John on this one, were it not for the fact that, if it was ever leaked that John and I agreed on something, we would instantly lose all our respective friends, including Don McCanne.
The fact, though, is that I have harped on the same theme, in the same manner, for over three decades now, influenced in good part by Milton Friedman's classic little book CAPITALISM AND FREEDOM. Additionally, my attitude on this one probably can be traced to the fact that my mother used a midwife rather than a doctor when I was born and, as everyone I hope would agree, I am living proof that midwives can produces truly superb babies.
I recall serving on an Institute of Medicine study panel on dental care just as President Reagan had ascended to the White House. A certain HANES study had found a huge unmet need for basic dental care among poor American children. Quite innocently, as a young punk economist, I proposed that, in the face of a shortage of dentists, we should let dental nurse practitioners on the New Zealand model do straightforward drilling and filling, in their own practice. A blind study in Canada which I cited had shown that on average well trained dental nurses actually did a better job (on school-age children) in simple drilling and filling than did dentists. My plea fell on deaf ears, whereupon I wrote a 30 page minority report that, alas, did not make its way into our study panel's final report. I must have stepped on someone's toes, I reckon.
. . .
One does not have to be a cynical economist to smell a rat upon realizing that most professional licensing laws are composed and legislated at the behest of the professionals themselves, rather than their customers. Paul Feldstein used to have a whole chapter on that in his text on health economics.
I also remember the huge and amusing fight over the question whether opticians should ever be allowed to dilate pupils.
Anecdotes on poor quality of NP care on this blog do not persuade me. There are plenty of anecdotes of poor care among physicians as well.
So, I cheer you on, comrade John, in this march for professional freedom. In the end we will win this fight.
John and I are not arguing that NPs have the same training and range of professional competence as do physicians. That would be patently absurd. GPs do not have the same training as neurosurgeons or OB/Gyns either.
But we are economists, and as such we always compare some baseline policy -- the status quo -- against a new policy.
The baseline is that many people just cannot afford to see MDs for less severe illnesses or simply can't access one for other reasons (e.g., rural areas).
The alternative we are espousing is to allow NPs to hang up a shingle that says NP, not MD. Friedman would make it illegal for an NP to hang up a shingle with MD on it.
So the choice we see -- especially for poor or rural patients -- is either no care (but theoretically only from an MD) or some relief, albeit from an NP.
After all, we send NPs out into the field with our combat platoons, not MDs. Ditto for ambulances.
There is no reason why NPs should not be electronically connected to MDs at a medical center or in a clinic, but they is also no reason why they should be made economically subservient to MDs.
They should be allowed to compete with doctors, within the more limited scope of practice for which they are trained.