Fix VA Physician Shortage With Physicians, Not NPs, Says AMA

June 15, 2016

CHICAGO — The American Medical Association (AMA) recently said it was opposed to a proposal from the Department of Veterans Affairs (VA) to solve a physician shortage there by letting its advanced practice registered nurses (APRNs) work independently.

Veterans' healthcare gets short-changed that way, the AMA contended.

On Tuesday, the AMA House of Delegates here offered an alternative fix for the VA's physician shortage: attract more physicians to the system with more generous loan forgiveness programs, including immediate forgiveness of their medical school debt.

"We want physician-led teams to take care of our vets," said AMA delegate David Rosman, MD, a radiologist from suburban Boston, Massachusetts, and cosponsor of a resolution that calls for loan forgiveness reforms at the VA. The House of Delegates overwhelmingly passed it.

The sprawling VA system of hospitals and clinics already operates two loan forgiveness programs designed to entice physicians to sign up, but they do not work very well, according to Dr Rosman and resolution cosponsor Melissa Garretson, MD, a pediatrician in Fort Worth, Texas. The VA's Public Service Loan Forgiveness Program (PSLFP) kicks in only after a physician pays down his or her medical school debt over the course of 10 years. And the VA's Education Debt Reduction Program erases up to $120,000 worth of debt over the course of 5 years, far short of the $180,000 on average that medical school graduates owe. And not every VA facility participates in the latter program.

The two physicians' resolution calls on the VA to forgive a new hire's loans immediately under the PSLFP, and it directs the AMA to work with the VA to improve its loan forgiveness efforts in general to better recruit and retain physicians, all for the sake of preserving patient access.

Making It Easier for Medical Volunteerism at the VA

Under another provision of the resolution passed by the House of Delegates, the AMA will work with the VA to make it easier for non-VA physicians to volunteer their time in its facilities.

Dermatologist Cyndi Yag-Howard, MD, who proposed the provision as an amendment on the House floor, said it is possible for physicians to treat patients in VA facilities as "workers without compensation," but red tape discourages them from doing so. Dr Yag-Howard, who practices in Naples, Florida, said she had to wait a year before she could see her first VA patient as a volunteer, and only after she took two tests, underwent a physical exam and blood work, and got fingerprinted as just part of the vetting process.

Other would-be volunteer physicians have encountered these bureaucratic barriers, so much so that a member of Congress introduced a bill, never passed, to remove them, according to Dr Yag-Howard.

"This Isn't All About Money"

In an interview with Medscape Medical News, Dr Garretson said the new AMA policy to encourage more physicians to work in the VA does not represent an economic turf battle with APRNs.

"The primacy of patient care has been my focus," said Dr Garretson. "Team-based healthcare is great, but physicians need to lead the team because of their training. [APRNs] don't have the depth and breadth of training that physicians do."

Dr Rosman added that the AMA's desire to help physicians work as volunteers at VA facilities proves "that this isn't all about money."

Turning to independent APRNs to solve a physician shortage, he told Medscape Medical News, "is not the right answer for patients."

APRNs include nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and certified nurse-midwives. Supporters of proposed VA regulations that would allow APRNs to work without physician supervision cite a report by the National Academy of Medicine (formerly the Institute of Medicine), which recommended letting APRNs practice to the full extent of their education and training to bolster the healthcare workforce.

The VA is accepting comments on its proposed regulations through July 25.

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