Desperate for doctors: Michigan looks to expand who can provide care

Facing serious worker shortages in health care, some Michigan lawmakers are trying to expand responsibilities for some workers or create brand new categories of workers
Some medical groups, however, warn those efforts endanger patients by watering down expertise in their fields
Other, though, say such arguments are about protecting turf

Faced with severe worker shortages of doctors, dentists and other health care professionals, Michigan is considering filling the gap by expanding roles for some workers, like nurse practitioners, and even creating entirely new health care job categories.

State lawmakers are proposing a couple of fixes:

Allowing nurse practitioners to prescribe and dispense controlled substances without a doctor’s authority. State law currently restricts NPs from “full practice authority.”
Temporary licenses allowing certain doctors who earned their degrees outside the US or Canada to practice in Michigan.
Joining interstate compacts, which would allow providers licensed in other states to practice here and have their local counterparts the ability to practice out of state.

Michigan is also expanding the use of other health care professionals like dental therapists to care for patients in areas lacking in dentists. This comes after the state in 2008 agreed to allow the creation of the profession.

The need is immediate.

Related:

As Michigan ages, there’s “a larger need for health care,” said Jason Lachowski, associate state director of government affairs of AARP Michigan. The organization, representing 1.3 million members, supports bills that would expand roles for nurse practitioners and allow other professionals to work across state lines.

As Bridge has previously documented, Michigan suffers severe shortages in health care — from primary care doctors to psychiatrists to medical assistants to pharmacy techs.

“If we are trying to open pathways for people in communities that need [to be] better served, we have to do something differently,” said Misty Davis, who has been overseeing efforts at the Michigan Primary Care Association to place dental therapists into areas without enough dentists.

But doctors, dentists and others at the top of the delivery system worry that expanding the roles of “mid-levels” such as nurse practitioners, physician’s assistants and dental therapists, would confuse — and even endanger — patients.

A “doctor” of nursing? A physician “associate?” A nurse “anesthesiologist?”

The ever-expanding terminology and expansion of professional licensing can cause “confusion” for patients who are already navigating a “cloudy environment” in the state’s health care system, said Dr. Tom George, the CEO of the Michigan State Medical Society.

“We have a shortage (of physicians) and we recognize the modern practice of health care uses multi-disciplinary teams,” George said. “Patients in Michigan deserve to have a physician available for their care.”

Debating the role of nurse practitioners

But Michigan’s rules are “outdated” by comparison to some other states, said Naila Russell, a nurse practitioner based in Traverse City.

Among other things, they block her ability to prescribe controlled substances to patients who need them, she said.

“In Michigan, you are still required to have a delegating physician,” Russell explained.

Russell, who acts as the legislative chair for the Michigan Council of Nurse Practitioners, said the controlled-substances delegation remains one of the last hurdles her profession faces.

“We can’t operate in a rural setting where there are no physicians who will delegate to you.”

Physician advocates like George, whose organization represents the state’s medical and osteopathic doctors, oppose multiple legislative efforts to grant nurse practitioners full practice authority.

Other states’ expanded scope of practice have “not made a dent” in making care more accessible to patients, George said. He points to studies that indicate some independent nurse practitioners take on non-primary care roles like cosmetic and IV hydration services.

While NPs – some of which have doctorates in nursing practice – are reimbursed by Medicare at about 85% of a physician rate, George is not convinced a change in practice authority would amount to savings, pointing to research that shows a rise in costs related to the nurse practitioners’ higher use of services like imaging and referrals compared to doctors. He worries that having more providers able to prescribe opioids would be a “step backwards” for Michigan.

Dr. Tom George, chief operating officer of the Michigan State Medical Society (Courtesy of MSMS)

However, a 2024 border analysis comparing states with full practice authority indicates measurable health improvements among patients. Other studies indicate NP roles can lead to cost savings among some patients while improving patient satisfaction and wait times. Proponents of nurse practitioner reform say the state has enough built-in opioid prescription guardrails to stop bad actors from taking advantage of the system.

Still, George said he’s open to modifying the current regulation.

“We’re at one extreme – we require supervision. And at the other extreme, you have total independence,” George said, calling for a more “flexible” written practice agreement that keeps doctors at the top of overseeing nurse practitioners.

The Citizens Research Council of Michigan is generally supportive of expanding scope of practice, concluding in a 2024 policy brief that financial costs from increased utilization should be weighed against “the significant toll the primary care provider shortage has on the public health and financial wellbeing of the state.”

Boots on the ground

In yet other cases, lawmakers are creating brand new roles in the state’s workforce.

Medication aides — a position that the Michigan Nurses Association opposed — began working in Michigan’s nursing homes in 2023, an industry dogged by short staffing.

Federal Health Provider Shortage Area (HPSA) scores map out underserved areas. The higher the score, the greater the need for providers.

And late last year, Michigan’s first licensed dental therapist — a mid-level position between dentists and dental hygienists — began working after the Legislature approved the role in 2018.

It took seven years for the state to set up administrative rules and rework Medicaid so that the aides could be paid. And a training program — the first will be at Ferris State University — won’t start for another few years.

“There are significant pieces that need to be worked out before we get boots on the ground,” Davis, at the Michigan Primary Care Association, said.

Nearly a decade ago, the Michigan Dental Association argued against the creation of dental therapists. President Dr. Cheri Newman told Bridge earlier this month it would have better served Michiganders to grow the current workforce of dentists and dental hygienists instead, with better outreach to high school students and expanded mentorships.

But others say too many Michiganders go without dental care as the state tries to recruit more dentists to underserved areas — positions that typically require eight years of school.

Dana Obey, Michigan’s first dental therapist, required instead just three years of school, and she began work in September at Bay Mills Health Center, a community clinic that serves under- and uninsured residents in the Upper Peninsula.

She was in her late 30s with infant twins when she decided to advance from a dental assistant to dental therapist.

With scholarships and financial help from the Michigan Primary Care Association, Obey attended dental therapy school in Washington state.

Building up the workforce of dentists sounds great, Obey said, but it’s impractical.

Dentists face hundreds of thousands of dollars in student loan debt — estimates have hovered around $300,000 in recent years, according to the research organization Education Data Initiative.

As a result, they’re more likely drawn to private practice in more densely populated areas — not low-paying public health-related dentistry in Michigan’s rural stretches.

“They are just finishing school with so much debt, and then you want them to go and work for pennies?” she said.

Next steps

The Michigan Academy of Family Physicians also opposes expanded roles for physicians assistants, arguing that fully-trained medical doctors have “distinctive skills, training and experience. Likewise, a bill to expand roles for nurse practitioners, it contends, is “dangerous legislation.”

The group also rejects proposed legislation that would establish temporary licensing for some internationally educated physicians, saying the bill lowers the standard of patient care.

Advocates for older residents, like AARP of Michigan, encourage expanding access and improving affordability for patients as the state ages, including bills for physicians, nurses, physical therapists, occupational therapists, dentists and dental hygienists, audiologists and counselors to state lines by joining interstate licensure compacts, allowing providers to live in-state and work elsewhere and vice versa.

Michigan is set to exit the Interstate Medical Licensure Compact on March 28, which the AARP Michigan views as “detrimental” if lawmakers fail to renew the state’s agreement.

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