How Nurses and Other 'Mid-Level Providers' Fill Growing Gap in Primary Care

By Jose Martinez, KPCC

Simmi Gandhi -- a family nurse practitioner at South LA's UMMA Community Clinic -- is at work early. When she calls a patient, she apologizes for waking the woman up. But she knew the woman was waiting for test results.

In Urdu, she tells the patient her mammogram shows the mass in the woman's breast isn't cancer. After Gandhi hangs up, she doesn't miss a beat: She starts debriefing for her next patient, who's been missing appointment for months.

"Looks like he has diabetes," she says. "I had asked for him to be able to get an appointment six weeks thereafter, so that was back in September. That was cancelled, and then he didn't come for two appointments that were rescheduled. And now he's finally back."

Simmi Gandhi is what's called a midlevel provider -- which includes registered nurses, physician assistants and nurse practitioners. These are medical professionals who are in-between physicians and lower skilled medical technicians and nurses. At the UMMA clinic, she provides a wide range of primary care people in need.

"A community like this has less resources," she says. "A lot of the folks that live here have less education as I'm sure everybody's aware, our educational system is stressed so the basic education people get around their bodies ... is low."

UMMA clinic sees many patients who have diabetes and hypertension but don't know how to deal manage their illnesses. Doctors often come at a premium in community clinics -- where salaries are lower -- so midlevel providers often shoulder the workload.

In an exam room, Gandhi examines her long-missing patient, Hamdi Badar, a 52-year-old taxi driver originally from Indonesia. He's had diabetes years, but because he's been AWOL from the clinic, it's now out of control.

Gandhi reminds him what poorly controlled diabetes can do. "Sometimes that can mean that you get problems with your heart, right, you remember that?" she asks him. "With your eyes? With your kidneys?"

Gandhi seems to have captured Badar's attention. "I didn't realize it was so bad like that," he says.

About 2,000 patients walk into UMMA every year. Simmi Gandhi sees up to four patients an hour. Without her and her fellow mid-level providers, UMMA couldn't care for as many people as it does.

Five minutes away, at St. John's Well Child and Family Center, family nurse practitioner Alexis Gomez is checking up on 74-year-old Rafael Baez. He has high blood pressure, diabetes and a history of heart failure. So Gomez questions him in Spanish  about his diet. Are you eating a lot of tortillas? No, says Baez. How about fruits and vegetables. Yes, Baez says. Gomez tells him that's good, because fruits and vegetables are important to his diet.

Gomez has an unusual vantage point. He was a doctor in Cuba and a midlevel provider in the U.S. He sees the importance of professionals like him to fill a yawning gap in primary care.

Gomez puts it in simple terms: If St. Johns' midlevel providers played hooky one day, it would be "a disaster," he says.

Dr. Padra Nourparvar is the lone doctor at the same St. John's clinic where Gomez works. He agrees with Gomez and says there's a "always a shortage" of primary care providers in their clinic.

But Dr. Nourpavar says that doesn't mean mid-levels can replace doctors. He says that'll be true even as the patient load swells next year with people who'll gain health insurance under the Affordable Care Act's Medi-Cal expansion.

"You cannot completely substitute physicians," he says. "Because then the quality of the care can go down. You need ... [some] people with more experience and higher education to also be involved, to make sure that the quality is not compromised."

Back at UMMA clinic Dr. Felix Aguilar its president and CEO, disagrees. "The future is not with physicians; the future of primary care will be with what we call mid-level providers."

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