The ‘doctor’ will see you

As an emergency medicine physician and administrator at Oroville Hospital, Dr. Mark Heinrich has options for his family’s health care, and his decisions stem from years of professional experience.

He doesn’t insist on a physician for every visit. Rather, the Heinrichs seek out midlevel providers: nurse practitioners and physician assistants, who perform many of the same functions as doctors and are becoming a more integral part of how medical care gets delivered.

“My family members see midlevels by choice,” Heinrich said. “For pretty much all the medical issues that we present, especially in primary care, an experienced midlevel can do anything a physician can do, and that’s extending into just about every other specialty practice.”

That’s because the law of supply and demand has stretched physicians thin.

The Affordable Care Act has added new patients to the ranks of the insured. However, some insured patients, particularly those on Medi-Cal, find many practices either not accepting new patients or requiring lengthy waits for appointments.

This is a consequence of the nationwide physician shortage, which is acute in rural areas of California and pronounced in primary care (i.e., general practice, family medicine, internal medicine and pediatrics). A recent study by the Robert Graham Center forecasts the state requiring 8,200 more primary-care doctors by 2030, representing one of the most severe shortages in the nation. Meanwhile, the training system isn’t keeping pace, as residency spots have increased less than 4 percent amid a population growth of 20 percent.

Even where there are more favorable ratios of physicians to patients, “the work requirements on doctors is increasing all the time,” explained Mike Wiltermood, CEO of Enloe Medical Center. “The cost and complexity of running a private practice is more and more difficult, there are more and more documentation requirements of physicians, so they’re not able to see as many patients as maybe they used to in the past, and that’s contributing to the shortage.”

Midlevels help fill the gap.

“The fact is that nurse practitioners and physician assistants have a lot to offer,” Wiltermood said. “This model allows us to do something we probably should have done a long time ago, and that is add more midlevels to physicians’ practices.

“I know a lot of physicians who over the years have had great practices using midlevel providers. Often they can spend a little more time with patients, where physicians themselves—especially if they’re bouncing back between the clinic and the hospital—just don’t have that kind of time anymore.”

NPs and PAs see hospital patients, too. Between its wards and clinics, Enloe employs 30 midlevel providers; Oroville Hospital employs 40.

“We’re finding that our patients are much better served in some settings with midlevel providers,” Wiltermood continued. “It frees up the physicians to take care of the complex needs. It helps ensure access for patients who may have routine problems, routine concerns that can be dealt with and managed by a midlevel provider. We have a long history of using midlevel providers for taking care of our patients, and rather successfully.”

With midlevels so common, patients have grown accustomed to seeing them. Paul Robie is one such familiar face. He got his start at Oroville Hospital 32 years ago as a paramedic, went to Stanford University to become a physician assistant, then returned to the area. Along with seeing patients, he previously supervised PAs at the Oroville Hospital outpatient clinics; now he manages PAs in the hospital.

“Our community is such a small community that, over time, people have come to know us and trust us,” he said. “We see the same patients frequently, so they’re used to us, and with some knowledge put out there to the general public and the medical staff, they accept us pretty well.

“Very occasionally we’ll have a patient, usually in the ER, who wants to see a physician, which is not a problem. But that’s not as much as when I first started.”

Specialization also has increased since Robie received his PA degree and branched out into emergency medicine. Midlevels can be found in dermatology, women’s health, pediatrics and even surgical practices.

Not surprisingly, demand for NPs and PAs also is rising. In fact, both Enloe and Oroville Hospital treat the hiring of midlevels as seriously as that of physicians.

“I think it’s going to be tougher and tougher to recruit midlevels,” Wiltermood said. “You literally need two physicians to replace every retiring one, not only because of the bureaucratic hassles that have increased, but because new physicians don’t want to put in 80 hours a week—understandably—and more and more they’re lifestyle-oriented people.

“We have gotten incredible work out of our past generations of physicians: 60, 70, even 80 hours a week is not unusual, and some physicians here in Chico put in even more than that. You’re not going to get that going forward.”