One thing is certain as California heads for a new health insurance era under the Affordable Health Care Act, better known as ObamaCare:
 
Almost all parts of the state will need more medical professionals to serve the additional 2 million to 4 million newly-insured Californians. Should they, could they, mostly be physicians? Or should other healthcare professionals like pharmacists, optometrists and nurse practitioners do some things now in the exclusive realm of MDs?
 
An optometrist – Democratic Assemblyman Ed Hernandez of West Covina – leads the effort to let non-doctors do more.
 
Good or bad? Try this real-life situation: You need care for distorted vision in one eye. You go first to the local optometrist, who mostly does eye exams (sometimes without dilation) and fitting of contact lenses.
 
You don’t know it, but a bleed in a small capillary atop the retina is causing the problem. It takes an advanced scan using a dye to determine this.  Not even all MD ophthalmologists are equipped to perform that in their own offices.
 
Will more people lose vision while seeking care from someone not equipped? Since optometrists are easier to find than MD ophthalmologists, will more people get treatment faster by going to them first and then being sent to an MD? Since optometrists are capable of diagnosing eye problems stemming from diabetes, high blood pressure and strokes, should they be allowed to prescribe drugs for those conditions?
 
You may ask similar questions about other symptoms and problems from early indications of cancer to ear infections, now often diagnosed by nurse practitioners.
 
Assemblyman Hernandez wants to let the state’s 16,000 licensed nurse practitioners (more highly trained than registered nurses) set up their own shops, not always supervised by MDs. He says most would still be under the aegis of doctors via today's array of healthcare networks. This could make care more accessible, but might it cause sophisticated diagnoses to be missed? There’s that question again: Does increased access for hundreds of thousands outweigh potential risks?
 
“Pharmacists are the most underused of all health professionals, considering their years of education and training,” Hernandez says. He would let them prescribe birth control pills and other types of medication, including vaccines. Would they know enough about patient medical histories to avoid errors? Would they  know which organ transplant recipients can receive vaccinations and what types? Pharmacists often give drug-related advice, generally on over-the-counter products or after patients show up with a doctor’s scrip. Hernandez believes the majority could handle much more.

More Med Schools a Panacea?

He notes that only one-third of medical school graduates go into family practice as primary, first-contact doctors. The rest become specialists. “We should let specialists handle the complex cases,” he said, adding that many doctors already have nurse practitioners performing routine tasks in their offices.
 
Behind this discussion lies that certainty of a coming doctor shortage. The California Medical Assn. would like to see more medical schools added to University of California campuses, the long-term solution. It will take years, though, and there would be more years for students to finish their studies, subsequent internships, residencies and fellowships.
 
Plus, there has been no great upsurge of documented medical errors in states that have expanded the scope of nurse practitioners’ work. Of course, delayed diagnoses and treatments don’t show up as errors.
 
Most doctors strongly oppose giving expanded privileges to any other health care professionals, even if Hernandez insists that no one would do anything he can’t do now. (Many pharmacies now give flu shots, and most patients with vision problems see optometrists first, anyway.)

Patient Safeguards?
 
The state medical association is adamant that non-doctors performing clinical services have direct supervision and the ability to consult a physician quickly for problems beyond their ken. Even MDs have long forwarded difficult cases to specialists.
 
The bottom line is that something has to be done to make more professionals available to more patients, in a way that fits the tight financial guidelines of ObamaCare.
 
Some officials suggest giving incentives for doctors to bring more other professionals into their offices, combining ophthalmology with optometry, for example. Or using more nurse practitioners in internal medicine practices.
 
Change is coming to healthcare because it’s coming to both health care pricing and health insurance. There’s already a battle to determine its shape.
 
Mr. Elias may be contacted at tdelias@aol.com. His book, “The Burzynski Breakthrough: The Most Promising Cancer Treatment and the Government’s Campaign to Squelch It,” is now available in a soft cover fourth edition. For more Elias columns, go to www.californiafocus.net