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Is There a Doctor — Or a Nurse — in the House? Scope of Practice Regulation and Health Care Reform

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Is There a Doctor — Or a Nurse — in the House? Scope of Practice Regulation and Health Care Reform AMERICAN ENTERPRISE INSTITUTE IS THERE A DOCTOR — OR A NURSE — IN THE HOUSE? SCOPE OF PRACTICE REGULATION AND HEALTH CARE REFORM PANEL DISCUSSION PARTICIPANTS: CINDY COOKE, AMERICAN ASSOCIATION OF NURSE PRACTITIONERS; BENEDIC N. IPPOLITO, AEI; R. SHAWN MARTIN, AMERICAN ACADEMY OF FAMILY PHYSICIANS MODERATOR: TIMOTHY P. CARNEY, AEI 12:00 PM–1:00 PM THURSDAY, MAY 11, 2017 EVENT PAGE: http://www.aei.org/events/is-there-a-doctor-or-a-nurse-in-the- house-scope-of-practice-regulation-and-health-care-reform/ TRANSCRIPT PROVIDED BY DC TRANSCRIPTION – WWW.DCTMR.COM TIMOTHY CARNEY: Thank you all for coming. I’m Tim Carney. I am a visiting fellow here, at the American Enterprise Institute. I’m also the commentary editor at the Washington Examiner. My work here at AEI has generally involved competition and regulation, and sometimes we’ve talked about whether regulation is actually harming consumers by taking away choices. But when I give an example on the spectrum of absurd regulations, at one end is requiring florists to be licensed before they can arrange flowers. On the other end, I use the example of airplane pilots or surgeons, that we wouldn’t want those — just anybody setting up — hanging out a shingle saying volunteering to cut you open for money. And “health care is different” is one of the arguments that we hear again and again during health care reform debates. So, on this question, regulation of the provision of health care, we find lots of differences across states. We find lots of lobbying debates, lots of questions. There’s questions of safety. There’s questions of choice. There’s questions of economic liberty. And that’s what we’re going to talk about today. We brought in three excellent speakers who will discuss this. It’s going to be very discussion based, so there’s not just going to be a Q&A period at the end. If you guys have questions, think of them, and I’ll turn to you so, you know, work up your questions early on and try to condense them into as short of a question and something that ends in a question mark, hopefully, when we do it. So let me first introduce our speakers. First, we have Shawn Martin, who is — and correct me if I get your titles wrong — vice president at the American Association of Family Physicians, vice president of advocacy. Is that correct? SHAWN MARTIN: Correct. MR. CARNEY: And we have at the other end another American association, the American Association of Nurse Practitioners. Cindy Cooke is the president of that organization. Ben Ippolito is an economist here at the American Enterprise Institute. He works on health care. I’m sure there’s more to his title, but I think that’s the adequate sufficient part for our purposes today. So I want to — so we’re going to start with Ben presenting just some background information that I think is very relevant for this. So take it away, Ben. BENEDIC IPPOLITO: Believe it on not, based on that introduction, Tim and I have actually met before. I am an economist here at the American Enterprise Institute, and I tend to focus on issues in health care. But what I thought I would do before we get to the very complex personal liberties discussions would be start out with some basic facts about what is it exactly that kind of underlies this whole discussion related to scope of practice and why do we think it’s an area that’s relevant for policymakers to consider. And so I wanted to start with a slide that’s basically how I feel like 80 percent of the health care talks I go to starts, with some version of US health care is extremely expensive. That’s not a surprise to anybody in this audience, I suspect. We spend a lot of money on health care relative to other things we could spend money on. We also spend a lot of money relative to what any other country seems to spend on their health care. And so there’s this tremendous public policy emphasis on, you know, how do we get this line to be a little bit lower? You know, we’re probably never going to a UK, but how do we restrain cost of health care in this country? But I think that’s at least one way to characterize this discussion about scope and practice, right? The fundamental question at least more broadly is: Are there supply-side reforms that we could engage in that could perhaps try and chip away at this high-cost rate and potentially change access and things of that nature? So given that we’re expensive relative to other countries, I think — and we’re talking about the supply side in health care — it’s useful to characterize what does the United States look like in terms of providers relative to other countries. And so a natural place to start is the flow of physicians, so the number of medical school graduates in a country. The United States — this is data from the OECD, and it’s on a per capita basis. The United States doesn’t produce a particularly high number of medical school graduates. It’s not inherently a good or bad thing. It’s just a fact. Obviously, the mechanism is that we have — we don’t just let anybody become a doctor if they go to medical school. And there’s only so many spots in medical school. And the population of this country grows faster than the number of medical school slots; therefore, we don’t have that many physicians on a per capita basis. That number isn’t growing particularly fast over time. There’s a little bit of growth over time, but it’s not particularly dramatic. And so what do you get if you don’t graduate that many people and it hasn’t increased that much over time? Well, you end up with a situation, unless you have massive physician migration, you end up in a situation where you don’t have a particularly high number of physicians in the country. Again, not inherently bad. It’s just a fact. You know, somewhere — the number probably should not be zero and the number should not be literally everyone in the country is a physician, and so there’s some optimal in there. I don’t want to say what that optimal number is. It’s just it’s relevant to know that we don’t have a particularly high number of physicians. And so you can kind of see where the arguments begin to start. Geez, we spend a lot of money; we don’t have that many physicians. Maybe I wonder if they have a lot of market power. So what if we could something to try to inject a little bit more competition, get some more providers in here? Could that be something that helps with our overall cost issue? And I think that argument is kind of crystalized when you look at the growth of other kinds of providers in health care. So physicians haven’t grown a lot. NPs and PAs and other nonphysician providers have grown quite quickly. And so when you look at this, I think it’s tempting to say, “Well, geez, wait a minute. We’ve got this huge supply of potential providers here. What if we really unleash them? Could we then really inject a lot of competition, drive down prices, increase access, and so on and so forth?” I don’t want to sit here and say that that is a correct or wrong argument but rather just say that I think that’s a reasonable of framing at least one of the key arguments that people make in this realm. And so I conclude with just this basic quick run of facts here with what I think is the fundamental question here. So there’s a reason that there are supply restrictions. Like Tim said, you don’t want just like any random person coming in and doing your surgery. It’s very hard for a normal person to actually observe the true quality of a physician. And so we might like the idea that there’s some basic requirements. You have to go to a certain amount of school; you have to have a certain amount of training to be able to do particular things. The question, of course, is: Where is that balance between ensuring safety and ensuring relative efficiency? And I think that’s really, fundamentally where this gets so tricky and what makes it such an interesting policy topic. But I think with that, I’m kind of interested to hear what our panelists have to say about it, so I’m going to stop there and maybe come back to those issues later. MR. CARNEY: Great. I do think that’s great framing. If there was any hesitance in my introducing you, Ben, it’s that I’ve actually avoided pronouncing your last name for the years that we’ve known each other. And then I realized that I had to say it right now. Ippolito is correct, correct? MR. IPPOLITO: I’ve heard it a lot of other ways. MR. CARNEY: All right. So I want to start with you, Shawn, give you sort of the first say. What is the important — how would you describe what you think is the proper way — you know, without detail, an hour-long speech, whatever — the proper way to divide up the scope of practice, divide up what doctors should be doing and what non-doctors should be doing, and in what ways.
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