What Influences Advocacy for "Doctor Nurses?"

We have posted many times on the external forces battering primary care physicians (family physicians, general internists, and general pediatricians) in the US. Whenever new fervor for cost cutting arises, the tendency seems to be to call them in as the usual suspects. Thus, primary care doctors have seen their reimbursement lag inflation (see our post here and a post from DB's Medical Rants here), while they are subject to an ever increasing bureaucratic burden aimed at decreasing their supposedly wasteful and overly expensive practices. No wonder fewer and fewer physicians are going into primary care, and more are leaving. They can make much more with less hassle and a "better lifestyle" in other specialties, especially those based on procedures. Yet it is hard to see how our health care system can work with ever fewer, and ultimately no primary care doctors. Health care systems in other countries, which may produce results as good as or better than the US, are much more focused on and supportive of primary care. When no American has his or her own personal physician, who will be able to diagnose their less than obvious problems? Who will be able to manage their inter-related chronic diseases?

Instead of making primary care practice a more workable proposition, however, the current fad is to find other ways to do primary care that do not really involve primary care doctors. For example, an article in the Wall Street Journal addressed the idea of making nurse practitioners get doctorates (but not medical degrees, heaven forfend).

As the shortage of primary-care physicians mounts, the nursing profession is offering a possible solution: the 'doctor nurse.'

More than 200 nursing schools have established or plan to launch doctorate of nursing practice programs to equip graduates with skills the schools say are equivalent to primary-care physicians. The two-year programs, including a one-year residency, create a "hybrid practitioner" with more skills, knowledge and training than a nurse practitioner with a master's degree, says Mary Mundinger, dean of New York's Columbia University School of Nursing. She says DNPs are being trained to have more focus than doctors on coordinating care among many specialists and health-care settings.

One wonders how much nurses will learn from this two year program which might be the shortest doctoral program ever proposed. Primary care physicians, of course, take four years (two mainly classroom, two mainly clinical) to get their degree, and then spend three or more years in post-graduate house-staff clinical training.

Nonetheless, Mundinger seems to imply all that extra training does no good.

A study led by Columbia's Dr. Mundinger and published in the Journal of the American Medical Association in 2000 showed comparable patient outcomes in patients randomly assigned to nurse practitioners and primary-care physicians.

Mundinger partially bases her advocacy of the "Doctor Nurse" on the assumption that nothing can or will be done to make it more possible for doctors to practice effectively in the primary care arena.

Dr. Mundinger, of Columbia, says the primary aim of the DNP is not to usurp the role of the physician, but to deal with the fact that there simply won't be enough of them to care for patients with increasingly complex care needs. As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

In addition to training in diagnostic and treatment skills, doctors of nursing practice can have hospital admitting privileges, coordinate care among specialists, help patients with preventive care, evaluate their social and family situations, and manage complex illnesses such as diabetes and heart disease, says Dr. Mundinger, who has been leading the effort behind the National Board of Medical Examiners' planned certification exam.

Note Dr Mundinger's acceptance (the use of the word "fact" above) that the decline of primary care physicians is inevitable. How well two years of training beyond the bachelors degree will prepare these advanced practice nurses to do what used to be done by doctors with at least seven years of training neither Dr Munginger or the article addressed.

In my humble opinion, the solution of our health care problems will not be the "delivery" of "primary care" by people with substantially less training than primary care physicians. The blog DB's Medical Rants has been thoughtfully addressing some of the misconceptions that may underlie this bad idea. One, which DB attributed to "suits" who control but do not really understand health care, is that primary care is basically simple, limited to care of minor acute illnesses and routine prevention based on guidelines. This ignores all the complexity and ambiguity and uncertainty that taking care of the whole patient entails. (See in particular the idea that primary care doctors must deal with the concept of the "long tail.") Primary care really involves dealing with less than obvious, often obscure diagnoses, coordinating management of complex and interrelated chronic illnesses, whose prognoses and response to therapy are difficult to predict, and dealing with intricate biopsychosocial issues. It may be harder and harder for primary care doctors to do these tasks, given that they are not paid to do many of their components, and they are besieged by conflicting and often nonsensical bureaucratic demands. But "doctor nurses" with much less training will find them even harder.

So why does this bad idea continue to gain traction? It may be that the influences behind its advocacy are not as straightforward as they seem. Let us revisit the WSJ article above, and particularly the advocacy of "doctor nurses" by Mary Mundinger.

That name should, in fact, sound familiar to Health Care Renewal readers. While Dr Mundinger is the Dean of the School of Nursing of Columbia University, she has some part-time gigs. In particular, she is on the board of directors of UnitedHealth Group , the large for-profit managed care organization and health insurer. As a director, she is supposed to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.] For that loyalty, by 2007 she had received (per the company's 2007 proxy) rights to acquire 345,930 shares of UnitedHealth, and in 2006 was paid $73,750 in cash and stock options valued at $412,575. That level of compensation might inspire some loyalty.

Presumably, it is in the interest of UnitedHealth to hold down what it pays for primary care. In fact, the company, like most other managed care organizations and health insurers, has gone along with the physician payment scheme used by Medicare, and de facto controlled by the shadowy RBRVS Update Committee, which has minimized payments to primary care, but paid for procedures much more lavishly (see post here). Thus Dr Mundinger's advocacy for primary care furnished by "doctor nurses," who would be less well trained and paid than primary care doctors, might serve UnitedHealth Group's interests.

But Dr Mundinger's loyalties seem even more complex than that. She has been known as a particular supporter of the former CEO of UnitedHealth, Dr William McGuire. A 2006 Pulitzer Prize winning article in the Wall Street Journal quoted her thus, "We're so lucky to have Bill. He's brilliant."

In fact, we posted often (see these posts here, here, and here from 2006 with links backward) about the hugely lavish compensation afforded to the Dr McGuire, and how this remuneration stood in stark contrast to the stated mission of UnitedHealth Group:

UnitedHealth Group is a diversified health and well-being company dedicated to making the health care system work better. The company directs its resources into designing products, providing services and applying technologies that:
- Improve access to health and well-being services;
- Simplify the health care experience;
- Promote quality; and,
- Make health care more affordable.

Controversy has swirled over the timing of huge stock option grants given to Dr McGuire (see post here), leading to his resignation in October, 2006 (see post here). More recently, McGuire agreed to pay back some of those options, although that would reportedly leave him with more than $800 million worth of options (see post here).

Dr Mundinger's support of McGuire lead two advisory firms, Institutional Shareholder Services (ISS) Inc. and Proxy Governance Inc, to suggest that institutional investors not vote for Mundinger in the 2006 election for UnitedHealth board members (see post here.) Thus, she seems better known for her personal loyalty to the CEO whom she was supposed to supervise than her unyielding loyalty to UnitedHealth Group's stockholders.

To make things even more complex, Mundinger also is a member of the boards of directors of Gentiva Health Services, and Cell Therapeutics Inc. Gentiva Health Services provides home care services. Cell Therapeutics Inc is a biotechnology company that develops cancer treatments. Per its 2008 proxy statement, Dr Mundinger received $127,531 in total compensation from Gentiva Health Services in 2007, and has received options to purchase 10,090 shares of its stock. Per its 2007 proxy statement, Dr Mundinger received $92,865 in total compensation from Cell Therapeutics Inc in 2006, and has received options to purchase 23,750 shares of its stock. Thus she has reason to have unyielding loyalty to the stockholders of these two companies. However, these companies' interests, to maximize profits from home care services, and to maximize profits from cancer treatments, conflict with the interests of the UnitedHealth Group to minimize what it spends paying for these services and treatments.

So trying to figure out the influences behind Dr Mundinger's prominent advocacy of "doctor nurses" is well nigh impossible. Dr Mundinger has an amazingly complex set of conflicts of interest. So where do her interests lie? - Improving clinical care and promoting clinical science and teaching (the academic mission of her nursing school)? Increasing UnitedHealth Group's profits by decreasing its payments for health care? Increasing Gentiva Health Services' profits by increasing the payments it gets for home health services? Increasing Cell Therapeutics Inc's profits by increasing what it gets paid for cancer therapies?

And that is, as we have said before, the curse of conflicts of interest in health care. Conflicts lead to confused thought, speech, and action. One cannot tell what interests lie behind the speech and actions of the conflicted. So health care policy advocacy by the conflicted, rather than leading to better health care for all, just leaves us in a fog of doubt and confusion.

But financial ties to various industries, regardless of the conflicts they produce, fuel the imperial pretensions of their academic health care institutions' leadership (see post here). So the universities and their leaders will not give up their conflicts without quite a fight. But the confusion about clinical care, about research, about health policy that swirls out of the ever more pervasive web of conflicts in health care means it's time for that fight to start.