The Wait Times Challenge: Search for Solutions Begins With Staffing
By Debra Wood, RN, contributor
The Veterans Affairs scandal has roiled Washington, D.C., and the nation, focusing on long wait times for medical care at VA hospitals and clinics and the risks veterans face due to delayed access to healthcare. But the same problem affects civilian health systems, too, in many states and communities.
The VA has already reached out to 140,000 people, to get them off of wait lists and into clinics for medical appointments with doctors and nurses. Congress reacted to the nationwide VA problem with legislation that includes $500 million to hire more doctors and nurses and to pay for some veterans to see clinicians in the private sector. The legislation also makes it a priority to hire in areas with the greatest shortages of providers. Government response points to the crux of the problem. Clearly, the link between wait times and staffing is well understood.
A recent article in The New York Times described how a physician shortage caused delayed care at the VA, where physicians work long hours with huge patient loads, and many quit without being replaced. The VA has been struggling in vain to fill a growing number of physician vacancies as wait times worsened, the story said. The long-festering impact on patient care eventually exploded into the nationwide scandal of delayed care for veterans.
A civilian problem, too
Delayed care is not only a problem for the VA. Many regions have wait times that, while not as long as at VA hospitals and clinics, remain very problematic. The Merritt Hawkins’ 2014 Survey of Physician Appointment Wait Times found that at 45.4 days, Boston has the highest cumulative average wait time for a physician appointment of the 15 metropolitan markets surveyed. The average wait times to see a doctor in all 15 markets was 19.5 days for family practice and 18.5 days for specialties.
We can shorten wait times by using midlevel providers, nurse practitioners and physician assistants, but the level of practice independence varies from state to state,” said Len Friedman, PhD, MPH, FACHE, program director of the Master of Health Administration program and interim department chair of the Department of Health Services Management and Leadership at George Washington University’s School of Public Health in Washington, D.C.
"Eighty percent of the cases physicians see, nurse practitioners could handle,” added Ora Strickland, PhD, DSc (Hon), RN, FAAN, dean and professor at Florida International University Nicole Wertheim College of Nursing & Health Sciences in Miami. “Nurse practitioners have been found to do an excellent job of providing care to patients with chronic disorders.”A survey of nurses and physicians reported in The New England Journal of Medicine in 2013 found 72.5 percent of physicians and 90.5 percent of nurse practitioners believed having more nurse practitioners in primary care would improve timeliness of care. Strickland reported a major demand for nurse practitioner graduates from primary care practices. She attributes that to the Affordable Care Act enabling reimbursement for nurse practitioner services. “Many private physician offices are using nurse practitioners to their full scope, because it makes sense and is financially more feasible,” Strickland said. “The issue is why are we not using nurse practitioners in the VA system to their full potential?”This problem not only exists at the VA. Some states, such as Florida, limit the number of mid-level providers a physician can supervise. And some physicians consider midlevel providers as competition, Friedman said.
However, shortages of nurse practitioners and physician assistants may be increasing, too. A 2013 survey by AMN Healthcare found that 36 percent of healthcare executives said that recruiting the two types of practitioners was difficult.
Richard (Buz) Cooper, MD, director of New York Institute of Technology’s Center for the Future of the Healthcare Workforce in Old Westbury, N.Y., said that physicians and nurse practitioners are not looking for jobs at the VA, because it’s a less desirable place to practice than other parts of the healthcare system. “The VA has trouble finding people, and the bureaucracy is so complicated,” Cooper said.
Unequal distribution, insufficient training
Friedman reported that an unequal distribution of clinicians exists, with more than enough clinicians in some geographic areas and not nearly enough to ensure good access in other locations, particularly rural areas, where hospitals also are in short supply. “The question is where are the clinicians, and are they in the right places,” Friedman said.
Although most experts agree a shortage of primary care physicians and some other specialty doctors exists, Friedman is not convinced that simply training more physicians will offer a solution, since newly minted physicians often enter higher-paying specialties. Yet, specialties also are reporting shortages, as outlined in a 2011 Career Resources article in The New England Journal of Medicine, indicating that wait times for dermatologists may be as long as three months.
Cooper said the true problem is that there’s not enough investment in the United States in training an adequate supply of clinicians to provide ready access to care. Support for medical education, including residencies, has been lacking for years and that contributes to the shortage.
"The only way you can limit expenditures is to limit the supply (of physicians),” Cooper said. “The shortage was predictable.”