Tuesday, May 26, 2009

Restarting with a comment on teaching

Well, I got started on this blog thinking that it would be both an interesting way to share some ideas about health policy--which was supposed to be a huge thing under our new president (as you can tell, I'm not so convinced anymore)--and to use it as a teaching tool. That makes it very appropriate that I am restarting this (after a bit of a hiatus) with a comment about teaching.

Last week, I had the pleasure of meeting some students with whom I will be working in the fall. They were a great bunch. Over lunch we had an opportunity to discuss a law related to nursing practice in their state. The issue is whether nurse practitioners (i.e. nurses who have been trained to provide primary care) should be allowed to practice completely independently or should be required to have a contract with a physician. Their state currently requires them to have a contract with a physician. That does not make a lot of economic sense. The nurses are trying to prove that to policy makers. Unfortunately, policy makers are not always driven by economics--they are driven by politics. And the physicians tend to be more powerful than the nurses politically speaking.

So, why doesn't this rule necessarily make economic sense? (1) Economics says that we should generally allow complete flexibility in the process of resource allocation. Requiring a nurse practitioner to find a physician with whom to contract limits nurse practitioners' choices. We should allow more flexibility unless we put patients at risk as a result. Evidence suggests we don't. (2) We claim that the number of primary care providers is insufficient. Nurse practitioners provide a potential solution that is actually less costly than physicians. Less costly solutions, as long as the quality is similar, are a good thing. (3) When a physician moves, dies, or is otherwise unavailable, under the system in which my students practice they have to close up shop immediately. Again, limits the opportunities for primary care. This can actually have externalities (i.e. effects on people other than the nurse practitioner and patient) if the patient ends up with an infection that can be spread to others and that they would not have gotten with higher quality primary care. (4) Perhaps we are worried about the quality of care that nurse practitioners can provide. Almost all evidence suggests that nurse practitioners provide care equal to primary care physicians. Economic theory suggests that nurse practitioners will protect themselves professionally by making sure they have physicians to whom they can refer patients who are out of their scope of practice. Failing to do so would put them at risk for malpractice.

So, the economic reasoning suggests that nurse practitioners should be allowed to practice without being mandates to have a contract with a specific physician.

How does this all relate back to teaching--the nurses with whom I was speaking actually thought that economics might be interesting after I explained things about an issue of interest to them using economics. Before that they had been a little worried.

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