The Medieval Guild Lives On

LawiStock_000005825665XSmalls concerning nurse practitioners (NPs) vary across states, but the three biggest regulations that affect NPs are those that limit their ability to write prescriptions, to practice independently and to receive direct reimbursement from insurers:

  • When doctors are required to supervise NPs when prescribing controlled substances, physician wages increase by 7 percent while nurse practitioner wages decrease by 14 percent.
  • Those restrictions also increased the number of physician hours worked by 6 percent to 9 percent while decreasing the number of hours worked by nurse practitioners by 6 percent to 14 percent.
  • The price of a well-child medical exam rises by 3 percent to 16 percent due to these laws.

However, none of these regulations appeared to reduce infant mortality rates or malpractice premiums

Source: NBER Working Paper.

Comments (17)

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  1. Dhor says:

    “but the three biggest regulations that affect NPs are those that limit their ability to write prescriptions, to practice independently and to receive direct reimbursement from insurers.”
    people pay more, nurses get less, who earns the money?

    • Matthew says:

      It shows that generally physician wages increase, while NP wages decrease. But limiting this ability is hindering more access to healthcare.

  2. Devon Herrick says:

    Increasingly, physicians don’t want to perform primary care, because it’s less-lucrative work and mundane. However, they are loath to abandon it to lessor-trained professionals. Doctors have a role in the continuum of care; nurses do as well. Nurse practitioners also have a role they can plan and it’s in consumers’ best interest to allow them to decide where they want to seek care.

  3. Thomas says:

    Eventually, they will be going away from seeing physician for primary care or annual checkups. Now at least, you spend more time with the nurse or nurse practitioner, then speak with the physician in the last 5 minutes of your visit.

    • Andrew says:

      This change is happening with a lot of medical careers. In pharmacies, technicians are filling, and in some cases checking, medications to be delivered and lots of the paperwork with insurance. Pharmacists are moving to a more clinical role.

  4. Walter Q. says:

    “Those restrictions also increased the number of physician hours worked by 6 percent to 9 percent while decreasing the number of hours worked by nurse practitioners by 6 percent to 14 percent.”

    Restrictions continue to harm the wages and hours of NPs. Since they likely a more affordable alternative to a physician, you would think there would be a shift in primary care.

  5. Jeff T says:

    The reason guilds existed in medieval times was to maintain the status quo of the members. For them working in groups assured them their survival, as they were harder to defeat working as a team. Successful guilds were those who outlasted the rulers, and could withstand any attacks against them. Not much has changed since. Guilds exist today, and many are still more powerful than government. Doctors are a great example. They have worked hard to achieve their status quo, and they won’t allow government to alter it. Thus there are these sorts of restrictions, which may go against public interest, but are approved and maintained because they are in the best interest of doctors. Until we disband the doctors’ guild, and treat them like any other individual, our health system will be flawed.

  6. Perry says:

    As a physician, I see no reason Nurse Practitioners could not practice basic preventive care, follow ups for chronic care, and most simple acute care visits.
    However, if there are complex cases or potential concerns, it would behoove the NP to have some medical backup.

    If we begin to use NPs for most primary care, it makes less sense for physicians to spend 4 years premed, 4 years med school, and 3 years residency, along with whatever debt is incurred.

    If I were doing it all again now, I would forgo the above for 6 years of training, less debt, less liability and become an NP.

    • Tony S says:

      Maybe the problem is the excessive training physicians are getting to perform tasks that NPs can perform with half the education that doctors receive. Maybe what we have to start doing is changing how we teach medicine.

    • Dick says:

      But many other phds who have a six-year-long graduate education earn much less than a doctor. So receiving a long education is probably not the right reason to request for higher salary.

      • Perry says:

        Not to disparage Phd’s, but their education is less and they have no liability like physicians do. Physicians also take call and spend sometimes long hours at the hospital.
        All of that aside, if you want a crew of providers who can treat uncomplicated cases
        then by all means provide an education path that will get you there, cost less for the student and cost less reimbursement for the patient in the long run.
        However, I would also like to have at my disposal(as a patient)someone with more extensive training and experience to handle my case if it gets serious or complicated. I am also willing to pay much more for that if life or limb is at stake.

        • Camilo J says:

          Doctors perform a social service. Those who practice medicine for the money made a mistake in choosing their profession.

          • Bernadette says:

            It is a win-win situation. Doctors definitely are high earners, although few of them commit that.I think a doctor is as important as a professor but a doctor generally earns two times higher than a professor..

  7. Paul V says:

    They are not lesser-trained individuals; they are trained in different forms of care. Both their knowledge and the doctor’s knowledge are required to provide the patient with a quality care. Limiting the participation of NPs is not only hurting their profession, but those restrictions are hurting the patients as well. Healthcare should be focused on the patient, so let’s make a reform that finds ways to improve the patients’ care, and that will make all the professions of the health sector better off.

  8. Sarah says:

    “The price of a well-child medical exam rises by 3 percent to 16 percent due to these laws. However, none of these regulations appeared to reduce infant mortality rates or malpractice premiums”

    How many of our regulations would that same general principle apply to?

  9. Barry Carol says:

    I’ve heard experts at the University of Pennsylvania’s School of Nursing say that a good NP can competently handle up to 85% of typical primary care encounters. Computer based decision support tools enhance this capability. I once asked an NP in a CVS Minute Clinic what happens when a patient comes in with a condition she can’t handle. Her answer: “We know how to call 911.”

    The Physician lobby has a decades long and largely successful history of trying to stifle potential competition at every turn as Princeton’s Paul Starr eloquently discusses in his 1982 book, “The Social Transformation of American Medicine. With the AMA now representing fewer than 30% of doctors, it’s time to allow NP’s to practice at the top of their license.

  10. Leslie Pham says:

    As a nurse practitioner student I see the importance of our profession being able to practice at the top of our license. I agree that physicians have extensive training and are needed to help with complex cases and such. I think that physician’s need to stop fighting to decrease NP’s abilities and instead embrace the knowledge and help that we can provide to them. Many physicians are extremely busy and could really benefit from a properly trained NP taking over the simpler wellness visits and standard follow up care cases. This would free up more of their time to focus on the complex patients. We should stop butting heads and start working as a team, this would be in the best interest of the patients and professionals alike. The physicians have such a strong showing in their own professional organizations that allow them to lobby for what they believe is in their best interest. As NP’s we need to step it up with our professional organizations to be able to have that strong backing and be able to lobby against those regulations that threaten to limit our practicing abilities.