Dear Chair Marzola, Vice Chair Jauregui, and Members of the Committee:

I appreciate the opportunity to submit this written testimony to the Assembly Committee on Commerce and Labor.

My name is Jeffrey A. Singer. I am a Senior Fellow in Health Policy Studies at the Cato Institute. I am also a medical doctor specializing in general surgery and have been practicing that specialty in Phoenix, Arizona, for over 40 years. The Cato Institute is a 501(c)(3) non-partisan, non-profit, tax-exempt educational foundation dedicated to the principles of individual liberty, limited government, free markets, and peace. Cato scholars conduct independent research on a wide range of policy issues. To maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 80 percent of its funding through tax-deductible contributions from individuals. The remainder of its support comes from foundations, corporations, and the sale of books and other publications. The Cato Institute does not take positions on legislation.

Nevada ranks 45th in the nation for active physicians per capita, with only 218.5 physicians for every 100,000 people.1 While most states require graduates of accredited medical schools to complete at least one year of postgraduate training and pass all three steps of the US Medical Licensing Exam before obtaining a license to practice medicine as a general practitioner, Nevada mandates that medical school graduates complete a minimum of three years of postgraduate training before they can receive a license.2 This exacerbates the problem. 

Medical school graduates apply for postgraduate training positions through the National Residency Matching Program. On the third Monday of March of each year, they learn if and to what program their application was accepted. During the rest of that week, unmatched applicants can seek unfilled positions, but an average of about seven percent of MD and DO applicants fail to find a program.3 This leaves them unable to hone the skills they developed in medical school, provide care to patients, or earn a living to help pay their student loans until the next March match occurs. 

One way to mitigate the shortage of primary care clinicians is for states to remove barriers that prevent APs from serving patients. In 2014, the governor of Missouri signed a law creating a new category of licensed professionals called assistant physicians (APs) for people who graduated from U.S. medical schools but hadn’t been placed in residency programs.4

The law allows APs to provide primary care in rural and underserved areas of the state with limited supervision from a licensed physician, with whom they must have a signed collaborative practice agreement. The Missouri Board of Registration for the Healing Arts started accepting AP applications in January 2017. Applicants are required to submit letters of recommendation, proof of graduation from an accredited medical school, and their scores from Step 1 and Step 2 of the USMLE. 

Several other states have subsequently passed similar laws, including Arizona, Arkansas, Idaho, Kansas, Louisiana, and Utah. Some states refer to these doctors as “Associate Physicians,” others as “Graduate Medical Physicians,” and still others as “Bridge Physicians” because they define the license as a bridge to the next match. 

Nevada should reduce barriers to medical school graduates becoming Associate Physicians by establishing a licensure category for them. Lawmakers should not limit the number of years Associate Physicians may practice. As these physicians work under supervision, they gain experience and refine their skills. Forcing them to stop providing care after they have become more skilled and experienced than when they first received their Associate Physician license makes no sense.

Limiting the number of years a physician can serve as an Associate Physician forces them to rush into a postgraduate training program—likely outside Nevada due to the shortage of positions in the state’s hospitals. I have argued that state lawmakers should allow medical school graduates to use their experience as Associate Physicians as an alternative pathway to unrestricted licensure as general practitioners.5 If most states permit physicians to practice as general practitioners after completing one or two years of residency and passing Step 3 of the USMLE, then three or more years as an Associate Physician—combined with mandatory continuing medical education and passing the same exam—should also be sufficient. In Nevada, where physicians must complete three years of postgraduate training to obtain a license, lawmakers could require Associate Physicians to complete additional years before qualifying for this alternative pathway.

To address Nevada’s severe physician shortage, lawmakers should refrain from restricting Associate Physicians to practicing only in rural or underserved areas. They should avoid requiring them to continue attempting to enroll in residency programs.

The Associate Physician to general practitioner alternative pathway could lead to innovations in how specialty boards certify clinicians. For example, nowadays, general practitioners who wish to specialize apply to specialty residency training programs. When they complete residency training, they take standardized specialty examinations and seek certification from specialty boards such as the American Board of Internal Medicine, the American Board of Family Medicine, the American Board of Pediatrics, and the American Board of Obstetrics and Gynecology. Thus, increasing the number of general practitioners might incentivize some certifying organizations to develop alternative pathways to certification that place greater emphasis on real-world experience. Certifying organizations might even develop various levels of certification based on applicants’ backgrounds and experience.

Increasing the supply of Associate Physicians and, in turn, general practitioners while promoting innovation in specialty certification would increase primary health care access and choice. In summary, Nevada lawmakers should lift constraints and allow medical school graduates to become assistant physicians. Ideally, they would use their experience as an alternative pathway to independent, general medical practice. By thus increasing the number and variety of primary care providers, state lawmakers would help improve primary care access while reducing costs.

Sincerely,