EVERY month Debbie Varnum of Shal-lotte, North Carolina, must pay a doctor's bill. It is not for treatment. Ms Varnum is a "nurse practitioner", a nurse with an additional postgraduate degree who is trained to deliver primary care. North Carolina, like many states, does not allow nurse practitioners to offer all the services they are trained to provide. Ms Varnum cannot, for example, prescribe the shoes diabetics often need to prevent the skin on their feet from breaking down. To do so, she needs the approval of a doctor. So Ms Varnum employs one. For about $1,000 a month, the doctor reviews and signs forms that Ms Varnum sends him. The doctor, she says, has a similar arrangement with five other offices.
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