The full implementation of the Patient Protection and Affordable Care Act will ultimately accelerate the rise of nurse practitioners and physician assistants as primary caregivers for an increasing number of patients.

So says Dr. David Troxel, medical director and secretary of the board of governors of medical malpractice insurer The Doctors Company, in an op-ed piece this week on

Troxel’s prediction was part of a longer analysis of why Obamacare will discourage those with a medical profession in mind from pursuing their M.D. Features of the law, such as its incentives for employers to shift how they reimburse health care providers from fee-for-service to “a bundled fee-for-performance reimbursement system,” will further reduce the already dwindling income of most physicians, and will apply pressure to see more than the 30-plus patients a day they now see.

“The nation’s physicians have deciphered the handwriting on the wall and are, unsurprisingly, alarmed,” Troxel wrote.

Industry insiders have been warning that the influx of new patients under reform, on top of the already growing physician shortage, will have profound implications for patient access to medical care.

As doctors are squeezed both on the patient visitation end and on the compensation end, budding medical professionals will seek other degrees that require less schooling.

“It’s far more enticing to become a better-paid specialist, and this simple fact adds to all the other aforementioned reasons we won’t have enough of these important doctors,” Troxel wrote. “Who will fill in the gap? Inevitably, nurse-practitioners and physician assistants, who are qualified to provide many preventive-care services and can play a significant role in chronic-disease management, by taking blood pressure readings or ordering and interpreting blood-sugar levels. When physicians have only 10 or 15 minutes to see a patient, they’ll have no choice but to delegate responsibilities to those professionals, who are able, in most states, to practice under the supervision of a physician.”

This trend, already gathering momentum, has raised a stir in the medical profession. As patients begin to view nurse practitioners and physician assistants as they once viewed doctors in the primary care setting, physicians see themselves losing both prestige and earning power.

Troxel appears to be among those concerned about the trend.

“Already, legislation in several states seeks to extend these professionals’ autonomy by allowing them to practice independently of physicians, but under certain protocols. Obviously, this legislation will be controversial, but my personal suspicion is that in order to increase the productivity of primary-care physicians, nurse-practitioners and physician assistants will ultimately be given more responsibility.”

This Troxel sees as damaging to the patient in the long run. “Unquestionably, the doctor-patient relationship will change,” he wrote. “The days of 45-minute doctor appointments are gone, along with the rapport that can be established in such relationships.”

Yet Troxel was not ready to proclaim an all-out medical Code Blue for his profession.

“Does that mean the quality of medical care will plummet? Despite all of these seemingly doom-and-gloom scenarios, I’m optimistic that’s not the case. I’m hopeful that if health care reform works as planned, the quality of care may well improve — and that the new performance measurements of patient outcomes will document this.”

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