Grocery list: Milk, eggs, bread and a checkup

By Ann Wlazelek Of The Morning Call

At King’s Market in Allentown, shoppers can not only pick up a quart of milk and carton of eggs but also park their carts to get a lab test, medical diagnosis or treatment for anything from pink eye to strep throat.

The Geisinger Health System, based in Danville, Montour County, on Thursday opened a Convenient Care Clinic in Aisle 2 of the grocery store for shoppers to get tested and treated for a variety of common illnesses and injuries, such as colds, earaches and minor sprains.

Run by a nurse practitioner, the clinic is one example of how allied health professionals can be used to a greater degree, as Gov. Ed Rendell proposed last week.

In his ”Prescription for Pennsylvania,” Rendell called for fewer restrictions on the practice of nurse practitioners, nurse midwives, physician assistants and even dental hygienists to increase access to primary care and reduce unnecessary visits to emergency rooms without greatly increasing costs.

Under his plan, regulations would change so that nurse practitioners could practice even more independently than the nurse at King’s, who enters patient information into a clinic computer for electronic review by a doctor at Geisinger.

Rendell’s prescription would allow nurse practitioners to perform physicals without physician assistance for the workers’ compensation program and for teachers as well as students. Nurse midwives could prescribe medicines, including prenatal

vitamins, and hygienists could do routine examinations and fillings without a dentist present.

”It just makes good sense to use people to the fullest extent of their training and ability, especially if it means removing restrictions that cost you and I money,” said Kate Philips, the governor’s press secretary. ”By making these basic health care services more affordable and convenient without sacrificing quality, you give people exactly what they want.”

Proponents — namely allied health professionals — say there is plenty of work for both primary care doctors and their highly trained, lesser-paid helpers. Other states and some countries give nurse practitioners, midwives and hygienists more freedom to practice independently than does Pennsylvania, they say.

But critics, mainly doctors, say collaboration remains the safest solution for patients. They say patients should know that a doctor or emergency physician agrees to see the more serious illnesses and injuries that exceed a nurse practitioner’s or physician assistant’s scope of practice.

Consumer advocate Art Caplan accepts both arguments but said the issue of what a nurse practitioner and physician assistant can do in Pennsylvania is less about safety and more about money, competition and control.

”This is a fight about turf, turf, turf, turf and safety,” said Caplan, director of the Center for Bioethics at the University of Pennsylvania and author of about 25 books on ethical issues in medicine.

He said there is little reason to worry about patient risks in the examples cited by the governor. ”If there are concerns about training, then train them,” Caplan said.

Other states, such as Alaska, might be more lax in regulations because they have fewer physicians and more difficulty recruiting doctors, the ethicist said. Pennsylvania, on the other hand, has more medical schools than most and a powerful physician lobby.

Nationwide, however, the trend toward broader use of physician ”extenders” appears to be accelerating. Regarding nurse practitioners, California Gov. Arnold Schwarzenegger recently made the same pitch as Rendell for looser regulations and more autonomy.

Oxford Health Plans, a Norwalk, Conn., health insurer covering 1.7 million members in Pennsylvania and four other states, began an experiment at the Columbia Presbyterian Medical Center in New York using nurse practitioners as ”gatekeepers” instead of physicians. The nurse practitioners can admit patients and write prescriptions without a doctor’s signature. They are paid similar rates for procedures but lower salaries than physicians.

And in the past six years, CVS purchased a chain of retail-based medical clinics and announced plans to open as many as 250 in drugstores nationwide, all run by nurse practitioners.

Physician assistants are allied health professionals too, capable of performing many of the tasks that doctors do, but they are more dependent on physicians than are nurse practitioners, said Christine Bruce, a physician’s assistant who directs the degree program at DeSales University in Center Valley.

”PAs will always be dependent on physicians to practice, because we are trained by physicians,” she said. ”The minute we would try to compete, they would not train us any more. We are there to extend, not compete.”

Still, Bruce said regulations have eased for members of her professional group as well. Regulations that took effect in November 2006 allow PAs to pronounce a death and perform screening physicals without a physician’s signature.

The changes also permit doctors to write a short list of medicines they don’t want a physician’s assistant to prescribe rather than the long list of those they would approve. The result, Bruce said, is her physician employer gives her permission to write prescriptions for any medicines except those that are experimental or controlled street drugs.

When it comes to dental hygienists, Dr. Sophia Kladias, who chairs Lehigh Valley Hospital and Health Network’s dental medicine division, said state regulations permit hygienists to perform preliminary exams and apply fluoride and sealants to teeth.

”They are not trained or permitted, however, to diagnose, plan treatment or perform fillings,” she said in an e-mail.

However, for dentist James Newman, who is sponsoring a dental sealant program in the Easton and Phillipsburg area, the idea of allowing hygienists to drill and fill minor cavities would be welcome news.

”I’m the only dentist in my office,” he said, adding that hygienists in New York are permitted to give injections of local anesthetic.

Locally, Rendell’s proposals received support for his general concepts but questions about the details.

”Really very few people will disagree with his goals of improving quality, access and affordability. That’s kind of like motherhood and apple pie,” said Dr. David Lyon, chief medical officer at Easton Hospital in Wilson. ”But there’s a quantum leap between dialogue and doing what he proposes.”

Andrew Sandusky, director of governmental affairs for the Pennsylvania Academy of Family Physicians, wants to know if giving nurse practitioners the right to practice independently improved access in rural or underserved areas of other states.

”Have those states’ health care costs and insurance rates gone down? Have their uninsured numbers gone down?” he asked.

Philips said the governor’s office does not have credible projections on cost savings. However, Families USA, a Washington, D.C.,- based consumer health care group, said it plans to study the cost effectiveness of using nurse practitioners and physician assistants to deliver primary care.

Confusion exists regarding Pennsylvania’s restrictions.

While press secretary Philips claims ”almost every state in the union uses nurse practitioners more broadly than Pa.,” the spokesman for the Pennsylvania Medical Society, Chuck Moran, said, ”I believe that Pennsylvania is in the majority of states with how it handles the nurse practitioner-doctor working relationship.”

Jan Towers, a nurse practitioner and director of health policy for the American Academy of Nurse Practitioners in Washington, D.C., said the governor’s position is closer to the truth. ”I live in Pennsylvania,” she said of her familiarity with the regulations.

To be licensed to practice in Pennsylvania, nurse practitioners must submit detailed collaborative agreements with physicians. But in 14 other states, no agreement or relationship with a physician is required, Towers said.

Also, a number of other states, including New York and New Jersey, have less restrictive collaborative agreements than Pennsylvania’s, she said.

Spokesmen for local hospitals said they have been maximizing the use of nurse practitioners and physician assistants for years.

St. Luke’s Hospital and Health Network, for example, employs 112 physician assistants and nurse practitioners in its hospitals, doctors’ offices, emergency departments and other areas, according to Susan Schantz, a vice president and spokeswoman. Quite a few work in St. Luke’s minor emergency or urgent care centers, she added.

Sacred Heart Hospital in Allentown and Easton Hospital also use physician assistants to examine patients with minor cuts, breaks and burns in the ”fast track” areas near the emergency rooms.

”It’s meant to decrease waiting times in the ER” for life-threatening emergencies, ”and seems to be working well,” said Ayn Carey, Easton Hospital’s spokeswoman.

For minor emergencies, the fast track shaved about a half-hour off the previous 21/2 hour wait.

Dr. Alex Rosenau, an emergency medicine physician at Lehigh Valley Hospital and president of the Pennsylvania Chapter of the American College of Emergency Physicians, said a similar fast-track system in place at LVH-Cedar Crest has worked well the past eight years, with doctors supervising physician assistants who care for patients.

”I would be concerned about directing patients away from a hospital emergency department for something that appears to be minor but could indeed be more serious,” he said.

Geisinger opened its first CareWorks convenient health clinic inside a Weis-King’s store in Clarks Summit in August 2006 and plans to open others in Easton and the Poconos later this year.

”We know that people need basic care and can’t always get to their doctors,” said Justin Walden, a Geisinger spokesman. ”This is a cost-effective way to help them.”

Stores are open longer than most physicians’ offices, he said, 8 a.m. to 8 p.m. Mondays through Fridays and 11 a.m. to 5 p.m. on weekends. Also, the clinics accept Medicare and some insurances, but require payment of some kind upfront. The average charge for those who pay out of pocket is $55, Walden said, or less than ERs and some doctors charge for visits.

”We’re not looking to take patients away from anywhere else, but in easing the burden,” he said about Geisinger entering the Lehigh Valley marketplace. The health system chose Weis-King’s because the chain got its start in nearby Sunbury, Northumberland County.

At King’s, on the clinic’s opening day, nurse practitioner Janelle Sharma of Whitehall had treated her first patient before lunch. The man, who declined to be interviewed, had stopped at the store’s pharmacy, then asked Sharma for a flu shot. Because he is covered by Medicare, he paid nothing for the service, she said.

Shoppers said they were surprised yet open to using a clinic sandwiched between the health and beauty products and take-out food.

”I think it’s a great idea as long as they accept insurance,” said Sally Markley of Orefield. ”I would use it if my doctor’s office was not open. ? Emergency rooms are always so packed.”

William Shaw, 64, of Allentown said emergencies would be the only reason he’d use the clinic instead of his own physician, but not because the Geisinger clinic is run by a nurse practitioner.

”I’ve been treated by several nurse practitioners, including one who works for my internist,” he said. ”They are very good. I have no problem with their care.”

Bill Larish of Wescosville said he would have used the clinic at King’s instead of a hospital emergency room last weekend if it had been open.

Larish, 61, works at the state store in the Shoppes at Cedar Point in Allentown, where King’s is located. If his stomach flu had come on during the day, he said, the clinic would have been more convenient.
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