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(The New York Times)   They make diagnoses, prescribe medications and order and perform diagnostic tests. And since they are reimbursed less than physicians, increasing the number of nurse practitioners could lower health care costs. Who could have a problem with that?   (well.blogs.nytimes.com ) divider line
    More: Obvious, health care costs, primary care physicians, American Academy of Family Physicians, Robert Wood Johnson Foundation, study design, medications, medical practices, health cares  
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4659 clicks; posted to Main » on 28 Jun 2013 at 11:01 AM (2 years ago)   |   Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



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2013-06-28 01:26:07 PM  
3 votes:

CWeinerWV: Scipio: HairBolus: For many years the AMA has been severely limiting the number of new doctors graduated, and thus creating an artificial shortage of doctors.

The plan is to turn doctors into executives where their main role is to supervise lower trained and paid NPs and PAs. A doctor as owner of his practice can continue to make a large profit while actually seeing very few of his patients.

This. I have absolutely no sympathy for MDs. They've controlled the AMA for years and through accreditation and state board requirements have severely limited the number of people who can become MDs. I have as much sympathy for a doctor complaining about this as I do lawyers complaining about paralegals. There are more than enough talented people with a bachelors that new medical schools could be opened and train enough new people that our medical system could be healthy and not cost prohibitive. While I respect MDs, I do not think we need to limit Med School admittance to the top 10% of college graduates. I am sure it would be possible to double that rate and still have very competent doctors.

Do a quick search of the AMA and find out what percent of docs actually belong to the AMA and feel that the AMA represents their view, then decide if that's a fair assessment of doctors as a whole.

/med student - have not met one doc that supports what the AMA does


Whether or not they do support the AMA is besides the point. The same can be said for the legal profession as well or any professional org. The AMA is the de facto representative for MDs in the political process. They have a monopoly on everything. They inflate the credentials necessary to open a medical school so the number of new schools that open are limited. You cannot tell me that MDs do not benefit as an extension of this practice.
Furthermore, I personally know many great and wonderful MDs, DOs, DDSs, etc. and I know on an individual level they are often good people. I just have little sympathy that they let the AMA run amok and for 30 years the AMA has successfully managed to prevent any significant increase in MDs being graduated. Only in the past few years under congressional pressure have they again started to let schools increase student class size and open new schools. Residency is also a joke for the average PCP as upwards of 80hrs/wk for 3 years is not really necessary for that position (other specialties I cannot comment on) and is simply another excuse to not allow more people to get into the field (AMA often complains they cannot graduate more students b/c the government hasn't funded enough residency programs). It is a big joke and anyone can see through the reasons why the requirements are so onerous. I find it humorous that the UK can graduate competent doctors in 4-6yrs, but the US takes 8+ (emphasis on the plus).
I believe the U.S. has probably the highest quality professionals in their fields in the entire world, but the medical field is different from other professions. There is no possible way that an individual can serve themselves and their own healthcare issues even if they wanted to take the risk to do so poorly. They cannot provide the drugs they need for themselves by law being a biggie. Therefore, unlike onerous requirements we can place on other professions, the medical field needs to be vastly more accessible and therefore a vibrant, competitive medical market is needed.
If we cannot have new MDs to serve a PCP role in the amount that's needed, then new roles will be created to fill that gap. Our society can barely keep up with the doctor shortage we currently have and with the huge increase in the next 10yrs. there is no way it won't get worse. Doctors are smart people, they should realize this. Hence why when the AMAs policies the profession was largely silent and profiting on is coming back to bite them as lower trained professionals can step on their coattails, I cannot help but to feel largely indifferent and somewhat glad to see happen (as it will hopefully save me a few dollars in the end).
2013-06-28 10:25:49 AM  
3 votes:

The Stealth Hippopotamus: Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.


NP and PAs can be a great addition to care in underserved areas if (and this is the part that idiot politicians miss) they work closely with a supervising physician to help them deal with areas outside their expertise. I work closely with many NP and PAs and they themselves admit that they are most comfortable dealing with relatively healthy folks with only one or two chronic illnesses and with regular preventative visits.
 For the older population who have 3-4 problems (like diabetes, hypertension, COPD) and multiple meds they admit these folks are out of their areas of expertise. If they are practicing independently without a Internist or Family Practice doctor to ask for advice they will be referring more folks to specialists and then you will see costs of care for a pt managed by an NP or PA zooming back up to where they are with an MD.
2013-06-28 12:33:34 PM  
2 votes:

Yes please: Lexx: Yes please: Lexx: The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.

Right, just like how Michelin artificially limits its star ratings instead of just assigning them to every fry cook who wants one.

Jim_Callahan: They don't have LESS training, they have DIFFERENT SIGNIFICANTLY LESS training.

No...it really does happen.  If the medical colleges REALLY cared about patient outcomes and not just limiting the # of doctors entering the workforce, they'd restrict the # of hours/week each doctor in residency works, and lessen the workload for each resident by increasing the number of residents used.  Overworked residents are a huge cause of farkups and bad patient outcomes.

It's less of problem than most people think. But the answer isn't to fill some of those hours with less competent people.  And if you want to expand the number of people in residency, you'll also need to increase the length of residency accordingly, and decrease pay proportionately.  What would you suggest, 25 percent?  So instead of a four year residency paying $50k a year for 80 hours a week, it's a five year residency paying $32k a year for 64 hours a week.  Who's going to take that job?


I am not aware of any study that demonstrates a significant improvement in patient safety or clinical outcomes in teaching hospitals after the 80 hour work week restrictions were adopted.  But the jury's still out on that.

You know what would significantly reduce the incidence of resident errors?  Require attendings to take in-house call, and be available to the house staff on demand.  Yeah, I know you can page them or call the attending, but it's not the same as being at the bedside.  But this will hamstring physician training.

Residents need autonomy to develop their clinical acumen.  Autonomy means they will screw up from time to time.  If they always kick difficult decisions up the chain of command, it will be harder to develop the skills, temperament, and mindset needed to manage their own cases when they're attendings.  If you're going to hold their hand the whole time and turn residency into a short-leash apprenticeship, then residencies will have to be longer, so that residents can acquire enough experience before being kicked out of the nest.

/adjusts onion belt and big shiny forehead mirror
2013-06-28 11:42:58 AM  
2 votes:
It's not the initials behind the name, but the name in front of the initials, that matter the most.  A person of integrity, with good training and clinical experience, will know his or her limits and act accordingly, and in the best interest of patients, the large majority of the time.
2013-06-28 11:33:46 AM  
2 votes:
For many years the AMA has been severely limiting the number of new doctors graduated, and thus creating an artificial shortage of doctors.

The plan is to turn doctors into executives where their main role is to supervise lower trained and paid NPs and PAs. A doctor as owner of his practice can continue to make a large profit while actually seeing very few of his patients.
2013-06-28 11:16:12 AM  
2 votes:
If nurses wanted to act like doctors and get paid like doctors, they should become doctors - in a perfect world.

The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.
2013-06-28 11:04:34 AM  
2 votes:
I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.
2013-06-28 10:53:28 AM  
2 votes:
I'm a doctor.  I employ NPs and PAs.  They're good, but not anywhere near MD level.  They simply lack the fund of knowledge that MDs have.  They are very good at protocolized specific tasks.
drp
2013-06-28 02:39:37 PM  
1 vote:

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


And this neatly encapsulates the entirety of the problem:  When the "consumers" of a service lack the knowledge or ability to tell the difference between "excellent" or "good" or "adequate" or "substandard" services, they resort to irrelevant superficial observations.

"My NP is more personable"
"My NP is more willing to talk"
"My NP spends more time with me"

 NOT
 

"My NP prescribed the correct antibiotic" (I have no way of knowing)
"My NP is managing my kid's asthma optimally" (My kid seems to be doing OK, I guess)
"My NP is held to high educational standards (I have no idea what those standards are or how they differ from physician standards)
"My NP correctly assessed my chest pain as being benignly GI in origin and correctly sent me home with some Zantac instead of referring me for costly, painful, invasive testing with nonzero risk" (All I really know is my chest hurt and someone in a white coat did some stuff and said some things)

It's a hell of a coup.  Insurance companies have convinced an awful lot of Americans that not only are their clients getting equal care from cheaper NPs, that they're actually better off with the less educated professional.  Think about that for a moment.  Your insurance company is saving money by sending you to a person with at best 1/4 the training of a doctor, and you're cool with it, because your NP is nice.

As a nation, we sure seem to get the government we deserve, and it appears we're well on our way to getting the "doctors" we deserve, too.

Caveat emptor.
2013-06-28 02:35:17 PM  
1 vote:

Galileo's Daughter: WhippingBoy: Why stop there? Why not let the receptionist make the diagnosis and prescribe the medication? Or the guy who cleans up all the medical waste?

That's a strawman argument.  NPs, by definition are RNs who are prepared to provide primary and preventative health care services.  It would be expected that they'd have at least a master's in nursing (MSN).


Np and PA are master's degrees.

There are DNSc and DNp which are nurses who ARE doctors.

A DNSc is a research-based degree.


DNP= 4 year bachelor's, 2 years ER experience, Master's degree with 2 years clinicals, then 3 more years school +2 year residency. Every bit the equal of an MD, just focused on different areas.
2013-06-28 02:02:45 PM  
1 vote:

Meesterjojo: CNA down the street, work 3 nights a week/end, and make $38,000 a year.


This is where I throw up the bullshiat flag. No CNA I've EVER met makes $38k, let alone working three days a week. I've looked at the average wages for CNA's, as I wanted to get my foot in the door of the med field at the lowest level, and it was barely minimum wage. In my state, average CNA pay is just under ten bucks an hour and that's pay that's ten percent above average when it comes to CNA pay.
2013-06-28 01:54:53 PM  
1 vote:
Future Nurse Practitioners are being forced to go terminal just to be an NP, that is, after 2014 all RN's wishing to specialize as a NP must become a DNP. Most of the programs I looked at directed the DNP education towards administrating other health care providers, setting health care policy, and actually not doing much hands-on at all. This is a primary reason why I jumped ship to pre-med, then med school.

Further, if you visit placed such as Allnurses.com, the huge community for Nurses and nursing students (the nursing equivalent of Student Doctor Network), you can see this topic is as old as the forums have been around. You'll also find interesting tid bits from current NP's: many, so they state, do want to do everything a physician can do. They do not want all the responsibility. They admit they do not have the same training. But they do, rightly, point out that they can ease the burden on physicians, and thus on our whole health care system in the U.S., by doing what they're already doing: handling patients that fall within their range of knowledge and training.

You can also find some lovely data floating around Allnurses showing that when NP's and DNP's were given the same licensing exams at a physician, just under 50% pass. This should be a no brainer.

Personally, I love the idea of a DNP, or some other nurse specialist, not being in administration, but handling cases that would otherwise clutter up my clinic. Hell. Yes. Please.

All of this said, though, I would like to note that Nurses get paid out of the door, physicians do not (that is, less than $40K/year).

Right now, with no training, and only having to pass a quick exam that any slope-browed mongoloid could get through with flying colors, I can be a CNA down the street, work 3 nights a week/end, and make $38,000 a year. The need is great, and for the work, the pay is very high.

That's more than some of us are looking at during residency, and barely as much as some of us are looking at right after licensing. Physicians don't make a lot for awhile. It takes time. The money issue is a non-issue.

Too, and the other big reason why I chose to jump ship from nursing, many (many) nurses decide to become nurses for the same reason late-in-life-teachers become teachers: they perceive it as easy, and the leniency given in their courses is insane. Scary insane. These are the dregs of society in many cases, hoping for something better. They'll reach it, but they'll deliver subpar performance which will result in conflict in the future, or a lowering of standards in this country. Mark my words. I simply thought better of myself, and my abilities.

That's not to say all nurses, or future DNPs are like this. Verily, I've tried to convert two of my good friends from undergrad that went on to become nurses to the physician side. Their reasons were strong. These are good, decent, honest human beings. The sort you hope you see if you need care, and the type which form the schema of a hardworking, highly skilled, nurse. This sort make up maybe 5% of nursing students.

I understand most American's place a low (loooow) value on health care until they actually need it, and then only want the best possible but at a rate cheaper than a Tijuana donkey show. I know. I've been there. But you can't have everything: not giving a single dime for STEM education, forcing science majors to trudge through a high price, complex, medical education, then telling them that they can't make any money for years- it's pretty no win. You want, want, want, but as a country, you're not willing to give, give, give.

Buck the fark up, America, decide what you want and let us know. If you want well trained, professional health care providers, physicians, specialists, then support us rather than take away our education, rather than raise the prices on our education, and rather than steal money from STEM everywhere. And too, realize, that nurses and physicians can work to alleviate a lot of problems, possibly even lower health care costs, but you're not (repeat: NOT) going to get a physician making as little as a nurse, or wanting to, until you/we as a country decide that helping physicians is a priority. Making STEM education as a priority. Your health and your future as a priority. I would gladly take a nurses pay, with a big farking smile and a thank you, if my whole education was paid for by you. If you promised not to sue me for every little mistake. And if you decide to respect what I tell you rather than contradicting me with your WebMD garbage.

It's give and take, again, and everyone just wants to take, take, take, and they believe, wrongly, that physicians are the greedy ones when many give, give, give much of their lives to helping others.
2013-06-28 01:43:05 PM  
1 vote:

The Stealth Hippopotamus: So in other words, this is madness?


No. This is Med-Express!


/kicks tSH into MRI machine
2013-06-28 12:27:55 PM  
1 vote:
A good NP is just about as good as a GP physician insofar as the most common ailments such as a minor infection, blood pressure, cholesterol, diabetes management and such. As long as they are wise enough to refer problem patients to a physician, I see no overall problems to this approach to stemming healthcare costs. On average, they do make more errors on prescriptions than physicians, but that's why I have to check over them I suppose.

The real problem with healthcare costs is the drug companies who spend on average 3 times as much on marketing as they do on R and D, and the fact that the government is insistent on incorporating private insurance firms into the new healthcare system. Why? The government can't provide enough bureaucracy? The pharmacy benefit managers make on average $10 per prescription, as much as pharmacies do, just for telling me, via a computer algorithm, that they will pay x amount for your script or they won't pay at all. They get money from pharmacies every time they sent an electronic request for payment, they get money from physicians who have to sign up for the privilege of prescribing for their own patients. They get money from the drug companies in the form of kickbacks for preferring one drug over another. They get money from your employer for claiming to review your drugs for safety and efficacy, when that has always been the pharmacists job, and it's just a smokescreen for more kickbacks anyway. Thats how these guys are able to claim to save businesses money. No one sees where the other monies go.

Now the government wants to give them tax money, constantly, with annual increases I'd bet, just like the military contractors get, ad nauseum, ad infinitum. It is unfeasible, untenable and foolish.
2013-06-28 12:27:18 PM  
1 vote:
It surprises me that people have yet to fully grasp that the doctors have deliberately created this 'shortage' by limiting how many doctors can graduate per year.

How else can they demand 6 figure incomes for so little work?
2013-06-28 12:22:12 PM  
1 vote:

HairBolus: For many years the AMA has been severely limiting the number of new doctors graduated, and thus creating an artificial shortage of doctors.

The plan is to turn doctors into executives where their main role is to supervise lower trained and paid NPs and PAs. A doctor as owner of his practice can continue to make a large profit while actually seeing very few of his patients.


This. I have absolutely no sympathy for MDs. They've controlled the AMA for years and through accreditation and state board requirements have severely limited the number of people who can become MDs. I have as much sympathy for a doctor complaining about this as I do lawyers complaining about paralegals. There are more than enough talented people with a bachelors that new medical schools could be opened and train enough new people that our medical system could be healthy and not cost prohibitive. While I respect MDs, I do not think we need to limit Med School admittance to the top 10% of college graduates. I am sure it would be possible to double that rate and still have very competent doctors.
2013-06-28 12:17:35 PM  
1 vote:

The Stealth Hippopotamus: Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.


There is not much correlation between price and quality in health care.  There are many studies that demonstrate this.

What are you getting when you pay more to have a doctor treat a condition, instead of a cheaper NP?  Presumably, better training.  It may be worth it for a complex condition that requires a higher level of expertise and training.  For a simple condition - the common cold, a simple laceration, a lumbar strain - the extra cost may not be worth it.

On the other hand, a doctor may be more likely to recognize that the low back pain is unrelated to the lumbar arthritis seen on the x-ray, and instead is due to a life-threatening aortic aneurysm.  But such instances are rare, and there are many docs who will not bother to explore differential diagnoses if the criteria for an obvious and common diagnosis are met.  (On the third hand... how do you know when to look for zebras when you hear hoofbeats?  You can't do it for everybody - takes too much time and energy, and costs too much. I guess that's what the "art of medicine" is about.)
2013-06-28 12:04:05 PM  
1 vote:
As someone who worked as a CNA in a nursing home while going to EMT school, I'm very happy there are license and credentiling standards for them.

They would be complete and total hell without them.
2013-06-28 11:44:47 AM  
1 vote:
I would often take the A-student NP with a lot of experience and knowing their limitations over an MD who doesn't. The general population has little understanding how specific all medical practice is now. If I am hit by a car crossing the street I would take the Trauma RN or ICU NP over a Ph.D/M.D Family Practice MD any day of the week. Even better, I would take a E-4 army corpsman making 20k a year if I got shot over the Top-of-the-class Dermatologist (the hardest specialty to get into...have to be brilliant), M.D./Ph.D making 750k/year. Also, in 14 states NPs and PAs can practice without MD supervision, and that number is growing. Most of the time, that is going to be a good thing, but remember, there are C students in any profession, and you need to have some accounting of that. In the medical field, if you don't do your job right, people can die.
2013-06-28 11:29:54 AM  
1 vote:

Lexx: If nurses wanted to act like doctors and get paid like doctors, they should become doctors - in a perfect world.

The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.


Bullshiat conspiracy theory is bullshiat.

Really if you think Doctors control medical school admissions you must be smoking something. They are one of the most valuable resources to a University (ie the tuition is sky high, you get the prestige of med school etc). There is no way Universities would allow a secret cabal of the AMA to tell them they cannot open a med school. If they could there is no way in hell one would have been built in the shiathole that is Mt Pleasant Michigan at CMU
2013-06-28 11:27:19 AM  
1 vote:

Yes please: Lexx: The problem with this, is that medical school are largely controlled by doctors and deliberately limit their capacity to create an artificial shortage of doctors, and thus inflate the demand & wages for existing doctors.

Right, just like how Michelin artificially limits its star ratings instead of just assigning them to every fry cook who wants one.

Jim_Callahan: They don't have LESS training, they have DIFFERENT SIGNIFICANTLY LESS training.


No...it really does happen.  If the medical colleges REALLY cared about patient outcomes and not just limiting the # of doctors entering the workforce, they'd restrict the # of hours/week each doctor in residency works, and lessen the workload for each resident by increasing the number of residents used.  Overworked residents are a huge cause of farkups and bad patient outcomes.
2013-06-28 11:15:06 AM  
1 vote:
They're fine for basic things.  If you have something more complex or need surgery or anything like that, you need an actual doctor.  But NPs and PAs are only supposed to work under the direct supervision of a physician, so there's definitely a limit to how much you can farm out to midlevel providers.  You can try to turn medicine into an industry like fast food as much as you want, as long as you're willing to accept the results.
2013-06-28 11:12:50 AM  
1 vote:

jjorsett: According to the article, NPs want to be paid the same, so where would the cost savings come from?


Volume.
2013-06-28 11:10:35 AM  
1 vote:

sandi_fish: I prefer Nurse Practitioners.  I found they are more personable, more willing to have open discussion should there be any questions, and spend more time with you.


I agree. Nurses are generally far better than doctors at communicating with patients and giving care. Plus nurses will admit when they or the system doesn't know something: doctors are trained never, ever to admit that might ever be fallible.

Doctors are basically highly trained technicians with terrible people skills.
2013-06-28 11:08:40 AM  
1 vote:
As someone who's eventual career goal is CRNA, I fult support my advanced practice nursing brothers and sisters.
2013-06-28 11:05:37 AM  
1 vote:
My experience with NPs has been nothing short of fantastic.
2013-06-28 09:55:38 AM  
1 vote:
Doesn't matter if you have a problem or not. This is how it has to play out. Why go though all the trouble and expense of becoming a doctor when the job market is looking for RN and Nurse Practitioners? True they have less training but people are proving again and again that price is more important than quality.

Which I think is madness, but hey I'm in the minority.
 
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