The assertion: The state should widen the use of mid-level practitioners and support the new community paramedic law

Kai Hjermstad, seen here with a patient named Jose, is among the first crop of "community paramedics," one Minnesota answer to supply health care in rural areas short on doctors. (MPR Photo/Jennifer Vogel)

Minnesota Public Radio's Ground Level initiative recently looked at the difficulty in providing adequate health care to those who live in rural areas of the state. As the Ground Level team reported: "While around 12 percent of state residents live in its most rural areas, the Department of Health estimates that fewer than 5 percent of doctors practice there." (see that article here).

The real problem is a shortage of trained health care professionals.

So rural areas turn to alternative means for bringing the patient together with the doctors. Some use technology - a video link called telemedicine.

And they are looking to other professionals to fill the gap. Nurse practitioners are being leaned on more.

Meanwhile, Minnesota is the first state to license these dental therapists, who fill the role of the dentist or hygienist. Minnesota is also the first state to establish certification for community paramedics to fill roles that doctors or nurses might.

The worry of these approaches is that such moves only replace licensed caregivers with cheaper, lesser-trained alternatives. The move will compromise the patient's health, say opponents of programs like the "community paramedic".

Those who favor the position believe that deploying providers like the "community paramedic" to do simple patient care will meet the challenge that a shortage of health care workers in rural areas creates.

Our debate will pose this question: With a shortage of health care workers in rural areas, should the state support mid-level practitioners - such as dental therapists and community paramedics - to fill the gap?

Opening Statement

Pro -Gary Wingrove, paramedic and chair of the International Roundtable on Community Paramedicine

According to the Kaiser Family Foundation website, between 1991 and 2004 there was a 6.5% increase in healthcare expenditures paid by Minnesotans. On average each Minnesotan spent an average of $5,795 or a total of $29.5 Billion. The US spent 17.6% or $2.4 Trillion of the National Gross Domestic Product (GDP) on healthcare in 2009 and it is estimated that it will grow to 19.3% GDP by 2019. When compared with other countries, the US spends considerably more on healthcare per capita than other developed countries and the health outcomes and life expectancy is generally worse. In rural America these statistics are even worse with higher prevalence of chronic disease and fewer healthcare providers per capita.

We are in an era of spiraling healthcare costs, increasing prevalence of chronic disease, resource issues everywhere (especially rural), and a desire to ensure that everyone has access to healthcare. What’s the solution? There is no simple solution but we know that doing more of the same will only continue the path we are already on. This debate is about whether the state should widen the use of mid-level practitioners and support new community paramedic law. At the heart of this debate is how to solve these problems without doing more of the same and expecting a different outcome. Instead, we should debate how to tackle these tremendous issues using the same or fewer resources in a smarter way. To do this, all healthcare providers, including mid-levels, nurses and paramedics, must work to the fullest extent of their capabilities.

When using medical personnel to their fullest capacity, education is a key component. Paramedic training is following the same model nursing did. Minnesota is one of the national leaders in being one of the first states to require that paramedic training institutions be accredited. The utilization of paramedics to the full capacity of their current scope of practice allows them to partner with other community resources, helping redirect patients to primary care, social services and community resources. While other countries have progressed beyond the U.S. in utilizing paramedics in their existing scope of practice we had the advantage in formalizing an educational curriculum with support from the Offices of Rural Health in Minnesota and Nebraska and colleges and universities from Nebraska, Minnesota, Nova Scotia and Queensland. So far, the curriculum developed here has been provided to over 40 colleges and universities in 5 countries and the US military. We currently have a team of educators from 5 states, with oversight of physicians and PhDs, transitioning the curriculum from version 2 to version 3. Community Paramedicine is entrenched in our higher education system.

The Community Paramedic is structured to be a gap-filler. In rural Minnesota, we have lots of healthcare gaps. We also have an underutilized paramedic workforce with an existing wide ranging scope of practice. Our paramedics are underutilized because in their current role they wait for an emergency to happen. In a smart healthcare system, especially in those rural areas where the ambulance is the only community healthcare provider, we can make better use of skilled people, by providing an appropriate education, being part of a collaborative team, and filling gaps of necessity. This is the Community Paramedic vision.

Regardless of how, we need to make use of the full scope of practice of every piece of healthcare our rural communities can support.

Opening Statement

Con - Carrie Mortrud, government affairs staff specialist, Minnesota Nurses Association

MNA Opposes Expanding the Paramedic Role to Include the Professional Responsibilities of a Licensed Nurse in the Community. This law will allow paramedics to practice public health nursing under the supervision of a doctor or medical director. Under current statute, medical directors and physicians cannot legally delegate nursing care. This law is a threat to the practice of nursing and a risk to patient safety.

Public Health Nursing - This law aimed at reimbursement stems from a role that is created through a curriculum for Community Paramedics, (CP). This curriculum is very similar to that of the Baccalaureate for professionals becoming certified as Public Health Nurses in the state of MN. Most of what is listed in the education is also specifically listed as Public Health Interventions as applications for Public Health Nursing Practice produced by the MN Dept of Health. This law, as written, expands the job function of a paramedic into the scope of practice of Registered Nurses. At minimum, Public Health Nursing shall be integral to the creation of the list of services a community paramedic could deliver.

Supervision and Delegation - The functions described in this law extend well beyond that which a registered nurse would ever delegate to an unlicensed health care worker; AND the law does not require a Registered Nurse to supervise the delegation of nursing care/s, nor will the RN be available to evaluate the patient’s response to that care.

Medicine is NOT interchangeable with Nursing - This law legislates that Medical Directors or Licensed Physicians must supervise the community paramedic; however, Medical Directors or Licensed Physicians cannot delegate nursing care and that is precisely what this law indicates the CP may do. If this is solely about payment for services delivered, MNA questions the origin of authority for allowing paramedics to deliver nursing care.

Care Coordination and Payment - If the intent is to better utilize downtime of trained health care workers, what happens to the client being seen by a CP when an emergency happens in the community? Who takes over the care of the client the CP was visiting? The purpose of this legislation is to address fragmentation of care and decrease the piecemeal approach to health care, but we feel it is contrary to that purpose. Finally, how many workers/programs is MN going to pay to deliver and coordinate care? Don’t we already have a pre-paid medical assistance, the newly formed Accountable Care Organizations and Health Care Homes?

As the husband, son, and friend of many nurses I can definitely say that the rank and file is not anywhere close to MNA's position on this. Most nurses are simply concerned that the ill, injured and infirmed are made whole again - the who, what, where is secondary at best. MNA is simply using legislation to protect their interests, which is contrary to the interests of the patients they then claim to be concerned about.

Sadly the Pro side of this argument is also lacking as CP's are only hoping to broaden the law enough to protect their interests as well.

State licensure of any profession is counterproductive to those who use the services. The statists claim that quality can only be preserved by a bureaucratic board but the problems that were supposed to be fixed by licensure never go away or worse yet become institutionalized. In the end the only certain outcome is diminished supply and increased pricing that inevitably follows.

The only sensible solution to this problem is to allow individuals to seek the level of care that they feel is appropriate. If a paramedic, layman, 30 year doctor, RN or barber is your choice, and you consent to dealing with the level of care you choose then you should be free to follow that desire (no doubt your insurance company will cover some of those services but not all). If doctors and NPs start losing patients to Paramedics they might then be more inclined to offer service in rural areas.

It is a shame that both guests in this debate are content with restricting health care delivery through licensure and legislation. They, and the people of Minnesota, would be far better served if they (Nursing and community Paramedicine organizations) promoted why their care model might be superior and letting the patients make informed choices.

if the nurses union is so worried about care in the boonies let them use some of that war chest of union dues to help support those nurses who wish to live and work in the outlying areas. Ah. That stops that discussion in it's tracks.

The nurses union is only about money. Period. You have people with making over $150 K a year as union nurses and they get darn greedy about that. If you start farming some of those rural jobs out to non union members, the unions grasp on a lot of these jobs begins to slip.

Anytime a union starts to mention maintaining quality, they are only referring to quality paychecks.

In the old days we had circuit judges, circuit preachers and dr's and dentists who had office hours one or two days a week in each town.

This is just the way it's going to have to be. Population levels in the rural areas are going to decrease as a matter of fact. We don't need a family sitting on every forty or eighty acre parcel like we did inthe past. The cost of production, the margins produced and the efficiencies of modern Ag methods just will not support that many people. With fewer people in each town and surrounding area, the idea of each town supporting a Dr, a Dentist, a lawyer, and other professionals is just not realistic, nor will there be enough people around to support the paychecks they need to justify their living there.

At the same time, there will be a demand for a local health person, almost a triage position. And why tie that person to only medicine or dentistry. Let's title the person CHP for county health person. This person can clean and X-ray teeth, take blood pressure, draw blood for labs, and has telecom hookups with Dr's and Dentists who can make decisions regarding wounds, X-rays, infections etc.

The nurses unions position on this is outdated and foolish. They are looking at it as someone trying to usurp their authority and financial standing. Perhaps they should look at it as a way to expand their rolls and roles in a non traditional sense.
As far as I can read, no one is suggesting these new positions could not be unionized nor is anyone suggesting the prime candidates for these positions would not be nurses.

I have a bit more nuanced view on this issue from Matt.

@Matt, I can see where you are coming from and respect your viewpoint that nurses have the best interest of their patients at heart.

Like you, I am also a husband to and father of nurses and know many physicians and other professionals.

Having been married to a career nurse for almost 40 years and having participated in her career development first through helping her study to become an RN and then word processing her papers when she was working on her Bachelors in Science degree and having participated in her Masters dissertation and now discussing issues she is dealing with in her Doctoral studies, I have a substantial grasp of the issues and the importance of certification and licensure.

Our daughter is also an RN who worked her way through CNA and LPN and completed her paramedics certification (did not work as one when she found out that it was almost impossible to find a decent paying job).

From my viewpoint I know there is no comparison between the skills and knowledge of a paramedic and a nurse. This is like comparing apples to oranges.

The paramedic is trained to deal with emergency situations only and has an extremely limited scope of responsibility. Their job is to triage a situation and remove the patient from the site to the hospital emergency room as fast and save as possible. That is where their involvement ends.

A nurse on the other hand has years of training that is substantially different from that of a paramedic.

Even as a nurse practitioner my wife found the responsibility of diagnosing a patient to require all her very significant skills along with a lifetime of nursing practice.

@Pete I have no idea where you got your information on nurse's union salaries, however, you are not even close.

The top wages in the St. Cloud hospital (non-union - similar pay scale) is around $58/hr. While that is significant, that does not come close to your assertion.

The top wages for nurse practioners from a survey published in their trade magazine is around $115,000 with many locations only paying around $60,000.

The only 'nurses' that are paid $150,000 or higher are nurse anaesthetists and there are only a few of those around.

Most nurses such as my daughter, make around $60,000 with 3 to 5 years experience. More with longer service.

I have mentioned the military model as the only system that could work as socialized medicine on a previous thread. It relies heavly on low to mid-level practitioners for speed as well as economics. I do not need a Doctor or RN when I know whats wrong with me or what I need. It is much like hiring an architectual firm to replace a bathroom door or a Detroit Automotive Engineer when I know all I need is spark plugs.

Overkill is what has driven up the cost of health care and the lack of care in rural areas. I can only think of 2 or 3 times in the last 30 years when I actually needed a Doctor.

@Eduard,
Just to be clear, I am in no way equating paramedics with RN's but there are times when they are just as competent to deal with a medical issue as an RN or even a Doctor. Would I let a paramedic determine if my child had an ear infection, strep, etc and then treat it? Any day of the week. It is a simple test with a straight forward treatment. If the ear infection returned two weeks later, or wasn't fully treated I could easily escalate to an RN or the level that I felt was appropriate.

As Gerald comments the military has done this for years. While in the Marine Corps I was regularly seen by Navy Corpsemen (not a misspelling but rather a long standing joke). In military combat training (boot camp after boot camp) I was on a 3 mile run in boots with pack and I felt my foot snap. When I was finally able to go to sick call the corpseman based on a visual inspection of my foot prescribed 800mg Ibuprofen, no light duty, keep on marching. As an 18 year old kid I was able to determine that this was an inappropriate diagnosis and went to see the foot doctor the next day (not supposed to do that without a referral from the corpsemen but I was successful anyways). As soon as I walked into the docs office he said "I can see you will be in a cast soon" I had broken my 2nd metatarsal bone that week and had actually broken my 3rd metatarsal a few weeks prior.
If I as an 18 year old could navigate my way through the autocratic military health system I have no doubt that most Minnesotan's could manage a wide variety of health asessment and treatment options.

Also, to clarify certification is a necessary and good practice - it does however fail when the state mandates that only certified individuals can perform services. I have no doubt that most hospitals would still hire only certified RN's but we all know that there are 10-20 year LPN's that can accomplish tasks that are reserved to RN's or even doctors. If I am okay with that LPN performing that task then state has no business prohibiting it.

@Gerald. You have to consider the consequences for making a wrong diagnosis. It is fine to use paramedics for colds and fevers, cuts and scrapes and other easily self-diagnosed ills.

Anything more then that is simply outside their scope of training and licensing. A lot more training would be required for these people to be able to go further then that. By the time they achieve that level of competency they are closing in on RN turf and will want to get paid similarly. They will also need liability insurance and pretty soon the intended cost savings will be eradicated.

I find the suggestion that paramedics need more work interesting. That is indeed the case as they have to be around on a 24 hr rotation for the few calls there may be.

Many times paramedics are part of a fire department operation. The same is true for fire companies as they now respond to more paramedic type calls then actual fire calls.

Such is the nature of providing emergency services.

I found the issue with the Norwegian Police having to drive to the attack site where many teenagers were being killed and then having to find a boat disturbing. Apparently it would have taken too long to get the helicopter ready.

This simply proves the point. This is what happens when there is no money around to have the luxury of people and equipment standing by on a 24/7 basis the result is almost 70 dead instead of a much smaller number.

We still have these systems in place, although this becomes more tenuous with every passing day. The current assault by right wing politicians on government and its functions will make it impossible one day to have these services available.

Using paramedics to provide rural health care so they can more efficiently use their time is a nice idea that is not yet practical.

I was hoping this would be a respectful debate on the merits of practice and professional standards. I'm frankly surprised at the personal attacks on motives.

Standards within a scope of practice represent a form of predictability that I can trust and depend on. I can trust a Paramedic to see if I have a visible injury. I can trust a nurse to use his/her full scope of expertise and knowledge to look at me holistically. I don't know what I don't know about my own health - especially if I am alone, vulnerable, confused. It is a benefit to me beyond measure to be have a system that provides highly skilled professionals to be in the right place at the right time to do the right thing.

@JLR,

You seem to have missed the basic point of the discussion...there are not enough highly skilled professionals that are willing to work in rural areas and provide the coverage that you desire. The alternative (as provided here...but certainly not the only alternative available to us) is to expand the legally permissable activities of a paramedic or let rural residents go without. Or, perhaps, you are offering another alternative where we require highly skilled professionals to practice in rural areas...sadly, I find that to be a more likely outcome than the sensible idea of liberalizing medical practice.

I'm the optimist - and good business practices back me up. When we have the right people in the right place at the right time, we save money in the long run.

...so why aren't doctors, PA, NP's filling the void in rural health care? Not enough pay, right? So we extract payments from other parts of the system to pay the higher salaries? Is there any limit on the distance one should have to travel to get to highly skilled professional? What would be the square mileage that we allocate to a doctor?
By using your same good business practices every small town should have all the same professional staff and equipment as Rochester, Duluth and the TC Metro. Market size is market size. The opportunity cost of living and working in a community of 5000 or 500 2 hours away from a metro area, and the opportunity it provides, is a real cost.

@JLR I fully agree with your last sentiment. We have a saying in Holland "Goedkoop is duurkoop".

As far as wisdom gained over thousands of years the Dutch can match the Chinese, we have a saying for just about any occasion which comes to mind when appropriate. This is a fully automated response...

I this case, freely translated, the meaning is "buying cheap is buying expensive".

I live about an hour north of St Cloud. I guess you'd say the area is rural. It actually seems like we have quite a few Dr's around here. (Not as sure about nurses and other support people. There always seem to be ads in the paper for nurses and technicians.) We also don't have a lot (any?) full-time paramedics, I don't think. You pretty much have the First Responders and the Fire Departments and they are all volunteers. No one is sitting around looking for something to do.

Health care here really, for the most part, is triage. You have the people with garden variety stuff like ear infections and pneumonia, that are obvious and easy to treat. You have the stuff that is more uncommon and probably ought to be referred to a specialist, and the "Somebody call the helicopter!!!" stuff. Someone has to be able to tell the difference, treat the easy stuff, and, one would hope, keep the patient alive until the helicopter arrives. I'm not so sure that a paramedic couldn't do that. The first level of patients could be seen by a paramedic or a nurse, who could then pass them on to a Real Doctor, if there was any question.

The biggest problem I've seen in this particular rural area is that even the simplest level of health care is horribly expensive. A year ago, I went in because I had bronchitis/pneumonia. I knew that seeing a Dr was going to be expensive (no insurance), so, in the farmer tradition, I treated it first with some antibiotics I'd gotten for the livestock. (Didn't work, but it was worth a try.) So, I went to the Dr. They took my temp. & BP, Dr. listened to my lungs, told me I had bronchitis, gave me a prescription that cost $25. I stopped to pay on the way out, but couldn't, because no one knew what the bill was. The bill, in the end, was nearly $300!!!!! I was NOT happy! Argued it down to the area of $125, but I still felt like I'd been robbed. Seriously, there's got to be a way to bring the cost of simple, garden variety stuff down to something rational. I took up maybe 10 minutes of the Dr's time, 10 minute of a nurse, and whatever the bookkeeping people put in. Not worth the money, but I needed the prescription and they've got me there because I can't get it without them. I could have told them what I needed myself (although I'll admit, I'm not up on what the drug of choice would be). I'd be all for a paramedic or a nurse telling me something I already know, if it was more affordable.

From my point of view, the problem in THIS rural area is the most people are self-employed and can't afford insurance and medical care costs more than most of us can afford. As it is, if I spend $300/yr to get a prescription, it still costs less than insurance would cost.

As a seior paramedic academic from Australia who is well informed about the development of Community Paramedic type roles in Australia, New Zealand, Canada, the US and the UK (they are called many different names), I think some of the argument presented here opposing the concept of a Community paramedic role in areas of need is a little bit circular. It is also rather insulting to our profession. Paramedics in many parts of the world (including many in the US) are very well educated and trained to undertake a wide range of roles that cross into other health profession domains. Sometimes their education is through vocational programs and increasingly through university programs that draw on the knowledge and skills base of a wide range of health professionals.

With this comprehensive education and appropriate regulation/registration paramedic students are provided with a sound academic base for new and emerging paramedic roles in under-served communities such as that of the Community Paramedic. My own research, and that of others, indicates that patients are less concerned about who gives the care, than whether those health professionals providing it are competent and safe.

At the university that I work at we have recently started a paramedic program that awards a Bachelor of Health Science and a Master of Paramedic Practice as an entry-level qualification for paramedics after 4-5 years full-time study. Nurses in contrast at this university undertake a 3-year Bachelors degree. To be fair, most of the paramedic programs in Australia also offer 3-year programs. A number also offer double degrees with nursing that acts as a dual qualification. In total, 19 universities in Australia are either offering or planning to offer paramedic programs.

In response to the issue of medical direction and the alleged risk of the medical profession taking over Nursing, I think that in the context of paramedics the answer is pretty obvious. The concept of Medical Control/Direction for paramedics is a very North American concept. In most developed countries that have strong paramedic education and regulation systems, paramedics work relatively independently under the general umbrella of evidenced-based Clinical Practice Guidelines that have been developed by a whole range of health professionals including paramedics, doctors, nurses and others as approriate. In other words, paramedics take responsibility for their own professional practice. My suggestion is that if nurses are concerned about medical direction of paramedics threatening their profession, they should help paramedics become a more independent health profession through the abolition of medical direction for paramedics.

Coming from a profession that has many friends and supporters in Medicine it is hard to fully understand why Nursing is so keen to be so completely separate. Paramedics are very independent and proud of their profession, but we don't feel a strong need to distance ourselves from Medicine. While many of us would say that we are more akin to Medicine than Nursing, we acknowledge that we will always overlap with Nursing and many other health disciplines. Nursing really should have little concern about the perceived threat from Paramedics - we see ourselves as a very separate and distinct profession.

What an interesting take on this issue. As a nurse (15 years) and an Acute Care Nurse Practitioner (3 years), I have learned an important caveat in the field of emergency medicine and intervention... Paramedics have an incredible sense for, and training to complete a comprehensive assessment in any environment. Nurses are fantastic holistic interventionalists, yes, thank you, Matt, however we often lack the experience and training to observe in the field. This realization helped me to appreciate the weighty value the Community Paramedic Program is bringing to my community in rural Colorado. Here, our Community Paramedics are not challenging nurses for their jobs, (and shame on those who think they are) they are complementing our skills with a well-developed skillset that nurses typically lack. Really, even the BEST ED nurse is not able to discern what the home environment was as well as the Community Paramedic can - and how could we? The patient present to us as they are, in our environment, whereas the Community Paramedic - under the direction of a physician who has a specific concern - is able to enter the patient's world and look at the challenges they face in their daily life on an immediate basis. The value of this observation and ability of the skilled Paramedic to respond with interventions within their own scope of practice is enormous. Our program in Colorado is early-on, and I can't wait to see metrics on the impact this program is having. I fully support these efforts!!

On the second, and more personal note for me, I think it is essential to outline what a "mid-level" provider is - - from my perspective, I am accustomed to Nurse Practitioners, Nurse Midwives, and Physician Assistants being referred to as "Mid-Levels" based on the following principles: We have completed masters' level or higher education in our field of practice, we can (in most states) function independently and/or bill directly for services. This is the distinction I believe that would set us apart from Community Paramedics.

Kim_O I had gotten pneumonia in the Army. I went to a Spec 4 medic who reached behind after checking my lungs and grabbed a bottle of codeine cough syrup. He said to notify them if I wasn't getting better by the second day. Bada boom bada bing, by the 4th day I was almost back to normal and back to duty.

I really question all of this emphasis on certification and licensing. It seems we ask this so we can nail someone to the wall if a mistake is made. As I recollect another issue about the cost of health care is mal-practice suits against educated and licensed Doctors and Nurses. I myself have had two strong case's I believe I could have easily won. Twice I have seen a Nurse ignore the Doctors orders and did what they thought was right. They were correct both times. In the end it is all about the individual care giver. I do not advocate not licensing, it just seems to be more of an issue to argue against lower level health care than actually looking out for the patient.

There is of course an increased risk of a misdiagnosis and anyone willing to accept it should be allowed to do so. Ok I see a paramedic, tell them I have the flu. They agree with me and we both are wrong, I instead have the West Nile virus, something a Doctor probably would have picked up on. I also understand that I as the patient share the responsibility in exchange for much lower medical costs.

I also say, big deal I got health insurance. In Kim_o's situation I would have had the same bill due to the deductable that I can ill afford. In the last 15years I have met that deductable one time. I too have avoided medical attention and treated myself. Yah sure, something major it would pay a chunk but would still leave me with a chunk to pay. Simply put, the system we have is not working.

Tuesday Rebuttal

Con - Carol Diemert, RN, MSN and Carrie Mortrud, RN, Minnesota Nurses Association

This debate touches on the very core of professional nursing – and its distinctive qualities beyond medical treatment. Medicine and nursing are not interchangeable disciplines. Nursing requires assessment and care in a comprehensive manner that involves a multitude of factors including nutrition, mobility issues, cognitive, family support systems, other multiple chronic health issues. For example, heart disease is a complex chronic disease which requires assessment of the total person, not just individual aspects of taking blood pressure, pulse, and weight, etc.

Chronic disease management, such as what would most likely be encountered in these rural circumstances, requires carefully assessing a patient, not simply collecting data at one specific moment in time. Paramedics are trained to respond to symptoms with a pre-determined set of tasks to stabilize for the purposes of transport to another appropriate point of care. They are trained within the medical realm and are accountable to physicians and/ or ambulance owners, and thus are not suited to perform nursing care.

Mr. Wingrove’s opening statement points to countries where the paramedic model experiences some measure of success compared to the U.S. cost and quality. We find it more telling that these countries all subscribe to a single payer health system. Specifically, Canada has integrated the use of paramedics as one of many entry points to a health system where the handoff between providers is much more streamlined and effective than our fragmented non-system that lacks accessibility for many citizens.

We also reject Mr. Wingrove’s statement about paramedics practicing to the full extent of their scope. Regulatory tenets any professional practice in this state requires all professionals to hold licensure. Currently in Minnesota, paramedics do not have a license.

Finally, if this is about better utilization of down-time as noted in the opening statement, imagine a situation where a true emergency arises – a family trapped in an upside down car, for instance. But the paramedic is across county in the midst of transferring the homebound patient with congestive heart failure from dining room to bed- just to fill up his time. That down-time suddenly becomes a dilemma that short-staffed nurses face every day. This is an example where the business model and the care model are woefully at odds. Business is obsessed with productivity – and assumes predictability, where you have controlled situations and things can be planned extensively. In contrast, much of health care can’t be planned. We need availability at unpredictable times. It’s true – care providers stand by at times. But we want to be there when you need us.

Doesn’t the bottom line really come down to “do we have enough appropriately prepared people to care for all those in need at the time we need them?”

Tuesday Rebuttal

Pro -Gary Wingrove, paramedic and chair of the International Roundtable on Community Paramedicine

The heart of this assertion is not a practice debate between nurses and paramedics. The pro perspective is not intended to be a ploy to take anything from the nursing profession or to pit nurses against paramedics – we make great teams in a variety of settings. The assertion is about the fundamental lack of healthcare providers of all kinds and how to meet patients’ existing needs while also addressing an increasing demand for primary care. This need is felt most in rural areas where there are fewer providers per capita.

Nursing and paramedicine are very different professions. Each provides value to the goal of appropriately and collaboratively caring for patients. Paramedics deal with complex medical issues on a daily basis. Paramedics are familiar with dealing with complex social and diverse economic situations and seek solutions that will get the patient what they need within the inherent limitations of the healthcare system. Similarly, nurses provide an invaluable role in the provision of nursing healthcare, sometimes doing so in ambulances and medical aircraft.

Paramedicine is mostly done in the field; in patients’ daily lives and in their homes. It is wasteful to ask the paramedic to disregard what they see, touch and anticipate by providing only one avenue of care; transport of the patient to the emergency department. Good paramedics are looking for the root cause of why they were called and looking for non-traditional ways to solve the problem at hand. Appropriate education is an essential element. This is the Community Paramedic program mission.

We need transition to a sustainable rural health system that can provide preventative, emergency and follow up care in a smart system of tiered and accountable care within medical homes, supported by all available and appropriate resources and professionals.

@Peter_O Peter, this is the first time that I have heard that paramedics have university training. Apparently what you do in Australia is not the same as the US system.

When my daughter went through paramedic training she did this at the local community college. Having seen her study materials and comparing that to my wife's education that now includes RN, Bsn, Msn, WHNP and now Doctor in Nursing there is no question that the educational level was closer and did not rise to the level of LPN.

Her job potential would have been to work for an ambulance service as an EMT. Since there were no jobs available and the EMT's teaching the course shed some light on the pay structure she decided to become an RN.

I don't think we are talking about the RN's being worried about competition as there is room for all.

However, I am well aware of the level of preparation needed to be a nurse as my wife is nursing faculty at a local college.

There is a reason for certification and the standards are very high, particularly in Minnesota. An RN with a Minnesota certification is welcome anywhere in the USA. That is not the necessarily the case with nurses from other states.

As a hospital administrator I have really enjoyed reading all sides of this debate. I think it wise to not allow this to be a turf-war and I encourage all readers to look at the big picture and whats at stake: there are not enough providers to care for our patients and the healthcare system is currently broken as the majority of our resources (especially hospitals) are geared toward meeting the patients need only after they are sick.

The con perspective seems to keep coming back to education. Paramedics are not the ambulance drivers of yesteryear and there is a big difference between EMT and paramedic training. Paramedics are some of the most innovative, smart, dedicated and thoughtful providers out there. They work in sometimes unsafe or uncertain environments and are there to care for another human being rain, snow, shooting or roll over. Today there are an increasing number of medics receiving advanced degrees and educational systems are improving to meet the increasing demand that the advancing healthcare field places upon medics. I don't praise medics at the detriment of nursing as I know well the phenomenal work nurses provide. I only want to encourage a clear understanding of the paramedic.

At the very root of the pro side of this argument is that additional training is needed and is available. It has been pointed out that improved education standards are not only being put into place nationally but should be transferred here from the international stage. We all need the benefit of an improved educational structure so why don't we agree that it is needed and push in that direction instead of saying that change is not possible.

I agree with the sentiments that we have to be smarter about how we solve complex problems. We need a system that will help people stay well longer and a reimbursement system that supports all providers to help achieve that end. Hospitals have to change how we care for people to ensure that patients don't return to the hospital for the same issue (this is positive but painful change in reimbursement). We need to do better at meeting patients needs before they have an acute episode that lands them in the ER and/or an inpatient bed but our business model is not geared that way. At the end of the day we all need to be creative in our thinking, set aside old practices and get to the work of fixing a broken system. Having more trained personnel in Community Paramedics to help with that huge task can only be a help, especially if we utilize a well established curriculum and work to integrate our efforts for the patients' benefit.

Apparently I haven't made my point. I am a multi-color printer. If the order is small and only one color the company does not waste my time and skill and the customers money, it is given to a small press operator to be printed. If the order is 2 or 3 colors and bigger it is given to a mid-level large press operator. If the job is 4 color process with 2 colors on the reverse it is given to me. If I have time to fill I can do those simpler jobs and have no qualms about stopping it to take up a complex order. With very rare exception it is should be no different in the Medical field.

@Matt Thanks for your perspective. From your position as an administrator you have a front row seat as to what is happening and the positive changes that are made to the healthcare system as a whole.

My window into the healthcare industry is through my wife's livelong involvement and my personal observations while surveying hospitals and nursing homes for the purpose of designing automatic fire sprinkler system to protect patients,staff and facilities.

As nursing faculty my wife and her colleagues are once again redesigning the entire nursing curriculum to provide baccalaureate nursing students with the latest changes in the demands of the healthcare industry. The new federal health care law requires substantial changes and improvements to the delivery system as a whole and preparation for those changes is in full swing at Minnesota's universities and colleges.

Matt, it's Sunday morning, I have a very bad cold and need some cough medicine. All the clinics are closed. I have no choice but to go to ER. I sit and wait because I am low priority. Meanwhile I sit and observe a nurse and EMT standing around shooting the breeze, both qualified to give me what I need. Finally the Doctor is free to see me, the nurse who now has something to do checks my vitals. Seriously how much is all of this going to cost me.

Eduardm, I applaud the work your wife is doing as I believe we must all "evolve or die," professionally that is, especially when such great change is demanded. Thank you also for your designs and work as they save lives!

Gerald, great illustration (excuse the pun) on several ways our system is broken. You're comments are about "triage" which someone has spoken about before. In your printing company the business model demands triage otherwise people would be paying the biggest and most complex printers to do simple jobs which would cost more and slow things down. In your ER example, where interestingly you were probably sitting in the "triage area," the healthcare system is typically set up so only the biggest and most complex printer can do the job.

Mid-levels have evolved out of necessity for triage. In any hospital every day, Physician Assistants (PA) and Nurse Practitioners (NP) and others work as a part of the medical team to care for patients and the system has been built to triage various duties to these mid-levels to decrease cost and keep things moving. PAs and NPs are often the only provider in rural clinics, rural hospitals and emergency departments and yet there are always more slots than there are trained professionals available to work in these settings. This goes for nurses and paramedics as well.

As healthcare professionals we should know how to triage. As healthcare professionals we are also responsible for the system. We all know that the system is fractured, expensive and too often provides poor care. We need to utilize the providers we have, train more providers at all levels, triage duties more effectively and stop examining our belly buttons and protecting turf when trying to move a mountain. The people we serve deserve better from us and there is room for everyone who wants to help. Community Paramedic is a wonderful innovation. Together we should look for ways to make it work and not for reasons it shouldn't.

Thank you Matt and great response. I do see some attempts to move in this direction. Our local clinic has a service of consulting your doctors nurse which has at time illiminated a trip to the clinic. I can also see where government interferes with the medical establishment in making some of the needed changes. Perhaps it will take a louder voice of the patients (customers) to get government in line with change.

The new breed of paramedics and EMT are very impressive.

Gary is spot on with this initiative. We have been doing a Community Health Program in Fort Worth, TX for 2 years with amazing results. The patients are much healthier, we’ve saved over $3 million in health care costs and reduced “9-1-1” and emergence department use by 51% in the target population. We’ve also returned over 11,000 bed hours to our local emergency departments for other patients awaiting care. Most of these patients need only gentle reminders about medication use and lifestyle change compliance. RNs are in very short supply and typically function in controlled hospital settings. They are also a pure cost when they are in the home settings. Paramedics can see these community health patients between calls, so there is very little marginal cost for using paramedics in this capacity – that is exactly what we are doing in Fort Worth.

While we can understand the reluctance of RNs to allow a new breed of care giver to provide this care, the fact is that the healthcare system is bankrupting America. We need to find better, more efficient ways of addressing the healthcare needs of our growing aging population. The definition of insanity is doing the same thing over and over, while expecting a different outcome. Traditional home health has been available for decades, but has not had the impact on the health of the patients, or the health of the healthcare system that community paramedics have had.

If we as a society do not try new processes to better manage the medical needs of at-risk or target populations, their health with continue to deteriorate and our costs will continue to escalate. An unsustainable model.

Congratulations to Gary and all his work on these efforts locally in MN and across the United States. He is a visionary and Minnesotans are benefiting greatly as a result of his efforts!

Bringing in practitioners will save money? Maybe in theory. The practitioner I get stuck visiting is constantly pushing unnnecessary tests and proceedures, which I refuse. My MD, on the other hand, is more thoughtful and inclusive in decision making; and avoids tests whenever possible.

So what's happening there? Is it professionalism on the MDs part? Do clinics benefit financialy from blood tests, thus securing a practitioners job? If a patient suspects selfish intentions from clinics and practitioners the health of that patient will be jeapordized, and in the end may cost more than if treated by professionals.

One other point. A financially strapped MD is synonomous with a financially troubled CEO or financier. Income is never the problem. Standard of living expectations are.

Patrick, it sounds like your practitioner must have sold Accidental Death and Dismemberment Insurance before landing this job.

There are other points to the Military model other than triage. "The medic reached behind and grabbed a bottle of codeine cough syrup." The war on drugs is really a fly in this soup. We at one time could buy codein cough syrup over the counter. It can now only be purchased with a Doctors prescription which requires a visit to see the doctor. Once or twice a year I buy generic sudephrine that I used to buy off the shelf. Now I have to see the pharmacist and fill out a Federal Form to prevent me from making meth. Will they allow Mid-Level health care workers to prescribe or dispense common drugs? Highly unlikely. The other aspect to the military model is you can't sue them. How long will it take before the cost of mal-practice insurance increases the cost of mid-level health care.

I think we have other problems to address before we can proceed.

@Gerald Prescriptive privileges start at the Nurse Practitioner level.

There is an effort underway between faculty at the University of Minnesota Nursing Department and the Governor's office to change the law to allow NP's to practice independently.

That change would make practitioners more available as they can then setup their own clinics without having MD 'supervision'. This move will also reduce the cost of health care as NP's typically cost and charge considerably less then physicians.

Across the country there are now approximately 5,600 individuals with the Doctor of Nursing degree. August 1st there will be one more when my wife graduates. The intent is that by 2015 all new Nurse Practitioners will have to have a Doctor of Nursing Practice degree to practice and will be able to call themselves Dr.

As you can imagine, the American Medical Association is not happy with this development, however, they can't stop it and they are not encouraging enough medical students to become General Practitioners. Everyone wants to be a specialist as that is where the money is. It is no fun to have to pay back over $200,000 in student loans and that is harder to do as a General Practitioner.

You will see a lot more DNP's looking after patients under the new healthcare law.

Wednesday Rebuttal

Pro -Gary Wingrove, paramedic and chair of the International Roundtable on Community Paramedicine

The entity controlling the paramedic national exam in the US is soon to require that paramedics graduate from an accredited paramedic training institution in order to take the national exam. Minnesota adopted an accreditation standard years ago. The Community Paramedic curriculum developed in Minnesota is given away freely, but only to accredited colleges and universities. We intend and request that the colleges and universities to use the curriculum as one ingredient of a paramedic degree program, but not for every paramedic degree program.

Every several years our healthcare payment system changes in an effort to control healthcare costs. In the past healthcare payments were driven solely on volume of tests, procedures, admissions, and the like. That led to lots of tests and procedures. In order to control tests and procedures, we switched to a system of lump sum by diagnosis. Lump sum payment led to earlier discharge. Early discharge has led to readmission. Readmission is leading to financial penalties. Readmission penalties will lead to something else.

We might be able to stop this cause and effect cycle by using collaborative teams of doctors, specialists, mid-levels, nurses, allied health personnel, and yes, community paramedics. All of these professions working together to help ensure compliance with care plans developed by those licensed providers able to create such plans, is good medicine. We must make sure these plans are not only issued upon discharge but evaluated for effect and adjusted when necessary, in an accountable care model based on the medical home concept.

Community Paramedics are ready to be part of that multidisciplinary team and help keep people from falling in the spaces in between. This is one goal of the Community Paramedic program. Other goals have been identified by people contributing to this conversation.

Community Paramedics are ready to work side by side with nurses and others, doing things that are appropriate within an existing scope of practice (but used in a different way), and under close supervision of physicians or mid-levels that have independent practice licenses. We are not and don’t want to be replacements. We also are not trying to be in places where there are no gaps to fill.

Wednesday Rebuttal

Con - Carol Diemert, RN, MSN and Carrie Mortrud, RN, Minnesota Nurses Association

The Nurses Association filed a rebuttal statement at 4 p.m. Wednesday. Click the button below to see the statement

Wednesday rebuttal

Eduardm that is certainly good news. There is a part of this health care crisis that remains relatively unknown. I would venture to say there are thousands of Minnesotans who do not seek medical attention because of the cost. There are two of us on this thread and maybe more. NP independance could have a lot of positive consequences. Is there some proposal in committee or bill being introduced that you can identify? I will contact my legislators to pledge support.

Healthcare costs continue to spiral while the nation's entire approach to healthcare suffers ongoing questions about quality of care and lack of access among the most vulnerable populations. Community paramedics represent an opportunity to address these issues in a manner that does not replace the efforts of public health nurses or any other aspect of the healthcare and social service systems, but rather provides the missing piece for vulnerable populations.

My research and professional experience show that high risk and high need populations overwhelmingly rely on EMS as their only source of care. This is especially true when an individual could be defined as being part of multiple high-risk populations (e.g. elderly and homeless or isolated senior with chronic medical conditions). My five year experience leading an EMS based outreach team targeting high users of EMS and entrenched homeless individuals in San Francisco demonstrated that these individuals were much more likely to inculcate a health improvement suggestion or plan when it was delivered by a uniformed paramedic.

In San Francisco we were able to dramatically reduce EMS and ER usage by several hundred of the top users (who were also demonstrated to be the costliest)of these and other services. This success has been replicated by other EMS providers including those in San Diego, Memphis and most notably Washington DC.

The Community Paramedic program Gary Wingrove represents is an international effort to codify the success of these pilot projects as a university level education that will ensure a uniform approach across EMS systems. The goal of the community paramedic is to engage in a high volume of clients in very specific interventions aimed at bridging the gap between other aspects of the healthcare and social service safety nets. In other words the Community Paramedic will assist primary care providers reach a maximum number of patients, but will not serve as an individual's primary care provider; they will get clients started with the long-term efforts of public health nurses and intensive case managers, but they will not replace them. Thus other aspects of the healthcare and social service system will receive badly needed augmentation, but they will not be replaced. The Community Paramedic represents an opportunity for healthcare in this country to finally achieve its goals of reaching everyone in a safe effective manner that reduces costs. The key is that this effort is seeking to broaden the education of experienced paramedics.

Finally, my experience shows that small expansion of existing EMS resources (which are comparatively much less expensive than other types of healthcare providers) can reach huge numbers of clients while dramatically improving the ability of other EMS providers to respond to emergencies. These resources provide the value added benefit of being an immediately available EMS resource during mass casualties or times when other resources are not immediately available.

Wednesday Rebuttal

Con - Carol Diemert, RN, MSN and Carrie Mortrud, RN, Minnesota Nurses Association

The economic issue of who is benefitting from this new community paramedic role has not been addressed. Rather, the discussion has focused on the assumption that by creating a new role, money will be saved in the health care system. MNA argues the root cause of any rural provider shortage is from lack of investment in primary care, prevention and health promotion. One writer talks about decreased costs due to reduced ER admissions/visits. However, how is one to know overall health care costs were truly reduced? We have no evidence that this "non admission" led to health savings in the patient's overall chronic condition.

It is unknown how the care was coordinated with existing health care providers. Thus, creating more fragmentation in the system and confusion for the patients. Who is reaping the payment benefis for this new type of community visit – the medical director, the ambulance companies or the hospitals that own them, etc?

If the focus really is on prevention and health promotion, why are public health nurses (whose primary purpose is this prevention/health promotion and care coordination in the community) being cut?

Without a single source of payment, the public health system currently does not financially interface with the reimbursement to hospitals because our current system of care in the U.S. is so fragmented.

I am old enough to remember when health care was only 6.7% of the family income. Logic would indicate we should undue everything since 1965. Many of the issues talked about were not issues back then. There are of course a lot of things that can't be undone. We have had some very impressive testimonies about the success of community paramedics. We do not need to be psychics to see what will happen if we do nothing new and/or different. It's time to pull up our bootstraps and git er done.

Thursday Closing Statement

Con - Carol Diemert, RN, MSN and Carrie Mortrud, RN, Minnesota Nurses Association

We are astonished that after four days of debate no one has addressed one of our major concerns which is; what happens when a community paramedic is attending to a client and a true emergency arises across town? Is the client abandoned for the emergency or is the response to the emergency delayed?

Overall our argument is, the U.S. health care system is broken. This discussion has highlighted and reinforced nurses’ concerns about our nation’s obsession with last minute, episodic acute care, with the drama of high-technology. The U.S. has the most expensive, least efficient health care system, with some of the poorest health outcomes in the world.

While MNA fully supports care coordination and working in teams with all appropriate personnel, we believe that this new role is only an extension of this acute care system which is dangerously flawed.

Thursday Closing Statement

Pro -Gary Wingrove, paramedic and chair of the International Roundtable on Community Paramedicine

I want to thank MPR for sponsoring this conversation and the Minnesota Nurses Association for participating.

I am proud to hold the title of being the first paramedic to be president of a state rural health association, and even prouder to say that I am no longer the only one. The time invested in holding a leadership role in the Minnesota Rural Health Association (MRHA) was invaluable in my work. Even though I grew up in really little towns in Iowa, what I learned from other MRHA members and from the participation of the Office of Rural Health and Primary Care staff in MRHA meetings about the whole of rural health forever changed what has become the focus of my life’s work and passion.

In the world of EMS, which is described by the federal government as operating at the intersection of public health, healthcare and public safety, nurses and paramedics are a cohesive team on the ground and in the air. For the seventh straight year, paramedics were recently voted by the public of Australia as their “most trusted profession.” Paramedics are not included in the USA Today/Gallup poll of the United States for professional honesty and ethics; but nurses have led that US poll every year since 1999 except for 2001.

Regardless of the setting, nurses and paramedics complement each other in caring for patients. In the oldest of the functioning contemporary North American models of Community Paramedicine, a nurse practitioner and community paramedics are a collaborative team in operating a clinic on a provincial island, producing exceptional patient satisfaction and significant reductions in transports to the off island hospital.

We created the Community Paramedic to respond to the needs of infrastructure poor areas by using an existing resource in a different way, within an existing skill set, through additional training provided by the higher education system, and under close medical supervision. This is the objective of the Community Paramedic program.

Ooops got a little emotional on the comment about a real emergency interrupting a patient. I have had my exam interrupted in an ER room so personnel could attend to a real emergency. It's a no brainer.

A couple of things. First, Michael, somewhat in my own defense, LOL, the drug I took is actually a human drug (package insert has human dosage info), but it also has veterinary uses. My vet will sell me a bottle of 500 (for around $75) because it's commonly used and he knows I know when to use it and when to call him for more info. (And he'd have a fit if he knew I used it myself, because he HAS to. I'll bet HE uses it himself too.) I think this actually might be an interesting topic for further discussion. The same drug, prescribed by an MD is going to cost a bunch more. But, I'll bet the pharmacy got theirs from the same supplier.
In answer to the "What if there's an emergency?" question. We are talking about RURAL health care, right? Well, if I have an appointment with my vet for 9AM & he gets an emergency call, he'll probably be late getting to my house. If he's AT my house, I'm going to tell him to do the emergency, (if it sounds like it's really an emergency.) I'd call that common sense.
I've been trying to sort out what we're actually talking about. Are we talking about these people working in a clinic setting, like nurse practitioners and physician's assistants, or are we talking about them working for the county, like public health nurses. I just checked, I guess our county has a public health nurse, but the role is mostly limited to kids, schools, and epidemics. The idea that was mentioned in passing, of someone to make sure people are taking their meds & visiting them at home is cool, but I don't see it happening. Who pays for it? Someone also mentioned the patient doesn't care what kind of degree the practitioner has, as long as they are compassionate and competent. "Right On" to that! A few of us in this area have talked about wishing we could send someone to med school and have them come back to work for the community. (Not the hospital or the clinic.) We need people at the local level that can handle the small stuff and refer people for the big stuff, and we need care you can actually afford. To get that, maybe we have to totally redo the system. The current system is a mess.

I would like to add that homepathic medicine is at an all time high. I have a sister-in-law who is a Dakota Medicine Women, If she were practicing I would probably call her before the Mankato Clinic. Actually if I lived closed to Kim_O I might mosey on down the road to see if she had any Teraomyacin. LOL

My experience with nurse practitioners goes back 20 years ago when there were only two sites in the US for an accredited program -- requiring an RN before taking the course. I was with Iowa Planned Parenthood where we had 13 rural clinics around the state and were our health care system was the largest one at the time. We paid for their schooling for 2 years (plus a salary)because of the value of what they could bring to these clinics that could not each have a physician on site. In many of these rural communities, even today, these clinics are often the only place to access health care screenings and other needed health services short of driving 100 miles or more. It costs less and is efficient. Today the nurses practitioners regularly talk with the physician via Skype, as well as making use of health records availability via a computer software system that houses all patient records.

Interesting comments, I believe that as Health Care professionals (HCP)we are here for the residents of the communities we serve, either it be in a large urban center or rural or remote area. Each area has its challenges and our roles as administrators and HCP is to work together to meet those challenges. As a great man once said "with challenges brings opportunity". We all know that the delivery of Health care can be a challenge. In rural Saskatchewan it is no different than anywhere else. The difference in this health region is that the Directors of the different health programs looked at ways of working together to provide those services, by utilizing resources available in communities in non-traditional roles. The rural health care team in each community is comprised of what HCP is available to those communities. If one team member is missing should the team fall apart? What if we only have one group of HCPs in that remote area? Should we not deliver services that are needed? Or should we be innovative on how we deliver the services? It wasn't easy for the Directors to open up to this concept, but we all had a common goal "patient first". It helped with the decision process and to bring down the silos that HCPs live in. In this region we are using EMS in non-traditional roles in our rural and remote areas(Home Care services, CDM education, Falls prevention program, etc). Without EMS these clients would not have been able to receive services they were accustomed too and depended on. This concept works both ways; we have areas where we are looking at utilizing HCPs as first responders where EMS is under resourced or response time is prolonged.
In closing, will Community Paramedics fix all our health care challenges? Doubtful :) but it is a beginning in recognizing that all HCP (with education and training) can be utilized in providing services for that "patient first" is truly why we are all here.

This is a very interesting conversation and one that should encourage all of us to keep seeking opportunities for improvement in our healthcare system. I am very concerned however that it seems that the stance provided by the Minnesota Nurse Association is fundamentally about protecting territory as opposed to solving problems. No where in their three statements has a solution been posed; only defenses of their practice and why Community Paramedicine cannot work.

I have had a chance to work with many nurses who are incredible providers and astute problem solvers. When faced with a problem they look for how they can get to a solution instead of giving up. I believe KFry is one of those nurses and I applaud the thoughtful response that was provided. I implore the MNA to seek leadership from within your ranks that will guide the powerful and needed profession of nursing into the next generation of healthcare.

All of us agree that the nation's healthcare system is broken. We all want change. There are issues of how to pay for primary and preventative care especially when Hospitals and the healthcare industry are built upon a very expensive system of acute care. Community Paramedicine is not an extension of this system it is actually an ingenious way to start to transitioning the acute care infrastructure toward a community health approach. Maybe hospitals should follow their lead and make a real effort to get emergency department patients into medical homes and keep patients from being admitted by helping keep them well...but wait, that would put us out of business, so never mind...

If you are reading this blog then you are an owner of our healthcare system (Taxpayer, healthcare professional, future patients, etc.). Demand a better system. Look for solutions. Seek out those people, professions and organizations who want to think creatively about how to overcome what is nothing less than a crisis. We don't have time, energy or money to waste on anything less than a full scale joint effort to fix our system. If a group is willing to step into a gap and try to make things better then we should figure out how to help them do it, safely and efficiently. There are no easy answers but business as usual cannot be accepted anymore.

Medical school leaves many graduates with big bills, no ? Do we not already have in place federal and/or State loan-repayment/loan forgiveness programs, @ a set percentage for each year a person practices in a rural area ? If not, let us begin. Source(s) for the $ ? Savings from closing 400, of our 800 overseas military bases. Savings, from increasing the age of eligibility for both Medicare and Social Security, to 67 for partial and 70 for full benefits. Increased revenue from congress doing what it does best: NOTHING. Take no action to again extend the Bush tax cuts. Let them ALL expire.

Once again the MNA try to assert influence to protect their territory rather than worry about caring for the needs of the underserved.
Nursing - I won't say leadership - has always been overbearing and interested in carving out and protecting their own perceived territory over anything else.
The fact is there will ALWAYS be some reason to object to any expansion of the medical team - but the idea that paramedics should not be used because they MAY be busy - one of the more ridiculous I have heard ...
The fact is that as a MEDICAL Provider who treats many patients daily I realize everyone at every level needs to be part of the team and there are MANY levels to care and that the idea of multiple levels as a team is the best way to treat as many people as possible.

Nursing Administration see nursing as separate and not needing to be part of that team nor that NP's should even be supervised - typical of their this is my territory and no one can tell me what to do attitude.

Luckily the rank and file of Nurses do not really support the MNA nor their ideals and are only members because they HAVE to be due to contracts ... instead CLINICAL NURSES are hard working members of the medical team interested in HELPING people - not carving out or protecting territory

The reason why Many MD's and PA's do not practice in a small community goes far beyond money .. it also includes the fact that in such a community you are on call 24 hours a day ... there are no colleagues to discuss problems with ... there are very few cultural things which can distract one from the stress of practice and additionally there are few - if any- high level resources that one can use to make diagnosis

Add the level of malpractice and it is a wonder that any clinician - let alone a specialist - practices in a small community ...

Here is a great space to weigh in on the health care debate... Click on the discussion happening at Ground Level

There are disparities seen for rural, minority and Medicaid patients.