The NP vs MD debate is missing the bigger picture

In coming years the US could see growing shortages in the availability of primary care physicians (PCPs). With the number of individuals seeking care increasing and the current medical system continuing to incentivize physicians to specialize, the number of available PCPs will decline proportional to the population. To fill that gap, Ezra Klein and others have asserted that expanded scope of practice will allow nurse practitioners (NPs) to serve as viable substitutes for primary care shortages.

While NPs serve a vital role in the system and meet need, the argument that they are a 1:1 substitute for PCPs (but for the greedy doctors and pesky regulations holding them back) is singular and shortsighted. The argument also fails to address broader policies that influence both NP and PCP behaviors. Policies that unjustifiably lead to the unequal distribution of caregivers, location or expertise, inherently parlay into unequal care for patients. Sadly, a broader scope than “freeing nurse practitioners” is necessary to meet primary care needs, as NPs are complements, not substitutes. Policy must address the need for more primary care and assist to realign the system to meet our country’s basic care and equality through redistribution.

Primary care is the foundation of the evolving health care system, with equal access the intended goal of the ACA. Along the way to meeting future demand for primary care, NPs can be increasingly utilized to meet the needs of Americans and improve the health of the nation. And let it be known I am a strong proponent and supporter of nurse practitioners and all non-physician providers and coordinators. However, the argument that most NPs practice in primary care and will fill the primary care gap, estimated at about 66 million Americans, is inaccurate. It isn’t a 1:1 substitute, especially given that models of the solo practitioner are vanishing in lieu of complementary and team-based care.

The US, unlike many western countries, does not actively regulate the number, type, or geographic distribution of its health workforce, deferring to market forces instead. Those market forces, however, are paired with a payment system whose incentives favor high volume, high return services rather than health or outcomes. These incentives are reflected in where hospitals steer funding for training, and in the outputs of that training.

Throughout the US there are geographic pockets that fail to attract medical professionals of all kinds, creating true primary care deserts. These deserts occur in part due to the unequal distribution of practitioners in the health care system, with our medical schools and salary opportunities producing low numbers of generalists across the board. We have even continued to see shortages in nurses throughout the US.

In fact, 2012 residency matching rates not only show continued unfilled positions in primary care, but that the rates of graduating minorities are highly skewed from programs. This contributes to even greater problems with finding primary care providers that reflect the populations they serve. Sadly, this is also true for nurse practitioners, where only 4.9% are African American, 3.7% are Asian or Pacific Islander and 2% are Hispanic. Further, the geographic distribution of NPs and physicians assistants alike is close to that of physicians. A June 2013 assessment found that the distribution for urban, rural and isolated rural frontier primary care providers is within a few percentage points for NPs and PCPs.

Ezra Klein was not wrong in his assessment that physicians are often influenced by income. However, it seems likely that financial incentives are drivers for many professionals in the health care sector, including nurse practitioners, registered nurses and physicians assistants (PAs). Dr. Andrew Bazemore, director of the Robert Graham Center for Policy Studies in Primary Care in Washington, DC has done significant research in this area. His perspective is that, “The suggestion that runaway health system costs could be contained simply by replacing higher salaries of physicians for lower salaried substitutes with less training misses the point — that cost containment will most likely result from optimizing primary care functions such as prevention, population management, care coordination, and avoidance of unnecessary referrals, procedures, ER use and hospitalizations of primary care providers.” Dr. Bazemore asserts that, “Achieving that level of effectiveness likely involves teams that include primary care physicians, NPs, PAs, behavioral and community health workers, and other important components, operating in a transformed practice setting.”

It is also correct that regulation on NPs is onerous and sometimes oppressive. Across the nation, regulation on NPs is exceptionally disjointed and often results in unnecessary hurdles for all involved, called scope-of-practice laws. Although impediments are common in the health care system, it is extensively difficult for NPs and similar non-physicians to break into a system that is deeply rooted in tradition.

However, by honing in on one piece of the puzzle, Mr. Klein missed the bigger picture. The principals of substitution do indicate that on the supply side, NPs stepping into roles for PCPs would better meet demand. But that is not the real world outcome. The broader landscape shows us that instead of a 1:1 substitution, nurse practitioners are compliments in the overall care system, important roles that fulfill many primary care needs.

Therefore, policy changes are still needed to improve patient health outcomes and forge a team-based relationship between care providers. Incentives to enter primary care and needed across the disciplines, as are models of team-based training that build on the strengths of each in managing whole persons and populations. Ezra Klein fails to note that most primary care shortage estimates implicitly include NPs and PAs already working in primary care while not accounting for the fact that NPs and PAs are choosing specialization over primary care for the same reasons as physicians.

Instead of an environment where NPs and PCPs are positioned to compete with one another, federal and state legislators should spend more time crafting policy that equalizes the distribution of care providers across the system. That redistribution means incentivizing, monetarily or otherwise, primary care clinicians to stay in general medicine and work in tandem with other providers. Whether it be the reformation of medical school, constructing a more honest approach to population health or restructuring pay scales and incentives, team-based medicine with improved access and outcomes should be the real discussion.

Brad Wright is an assistant professor of health management and policy who blogs at Wright on Health.

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  • ninguem

    If the NP’s want pay equity for the same work, which is not unreasonable if they are doing the same work……..then where is the cost savings?

    • DrPatient

      You can’t pay a CPA to do a Lawyers work…they receive different training. That is the point of this article and it is spot on from start to finish.

      • ninguem

        Fair enough, and I don’t really want to get into that can of worms, my point really was…..where is the cost savings, if pay is the same?

        • Guest

          Why do you claim that NPs care about cost savings?

          I don’t think anyone wants to pay NPs the same as MD/DOs except NPs. They don’t get to make the decisions though, and that’s where the cost savings come in.

          • NPPCP

            Most insurance plans pay NPs and physicians the same “Guest”. Those who represent us played a large part in making the decision. So yes, we do get to “help” make the decision. Tit for tat.

          • Guest

            I didn’t realize they were paid the same by insurance companies. Thank you for informing me.

          • Cyndee Malowitz

            There are only a couple of states where that’s happening. In Texas, NPs are reimbursed up to 50% LESS than physicians for the same work. Now, that only applies to NPs who own their businesses. When NPs work for physicians, the physician is reimbursed at their rate for the NP’s visits. Doesn’t make sense does it?

            If docs want NPs/PAs to make less than they do, then they should not get reimbursed “the doctor rate” for their NPs/PAs services. If that ever happens, you can bet the docs will begin supporting equal pay for equal work. Can’t wait to see that happen!

          • guest

            Not sure why you are having trouble with this one. Who should care about cost savings? NP’s or the payors ( Medicare, health insurance companies?)

  • Kristy Sokoloski

    Lawmakers can try all they want to when it comes to trying to create legislation that is supposed to equalize the distribution of care providers across the system, but unfortunately no matter how hard they try the end result is that no one is going to be happy with the outcome.

  • Anthony D

    From my previous post!……..

    Its amazing how NP’s think they can do a better job then MD’s. Its
    like what’s happening in Anesthesiology! The CRNA’s think they can do
    just as much while providing a greater quality then the
    Anesthesiologist, and pushing for authority!

    The Private and Government insurance programs like them because they
    can pay them less while they get out of school faster to work in
    hospitals/clinics.

    What it really comes down to is, “how to pinch the penny even
    more”and its getting worse now in all specialties and in primary care!.

    It’s similar to what happen in the 1990′s when illegal immigrants
    were replacing union bricklayers. Why? Because they were easy to
    substitute and are cheaper to pay!

    Sounds a little similar with the NP’s huh?

    • May Wright

      Your analogy doesn’t really make sense. Joining a union simply requires forking over a bunch of money. It doesn’t say anything about the training, experience, qualifications or quality of those who have decided to do so.

      A doctor and a nurse have difference skills, different training, different qualifications. This is not the case with union vs. non-union bricklayers.

    • valerie saenz

      Dear Anthony. My physician colleagues were never in a competition to “do a better job than Valerie”. We collaborated as a team to do a fantastic job for our patients. Some of my skills were better suited at getting certain tasks done, which freed up the physician to take on more complex situations. I never was a substitute for anyone. Thanks for the comparison to a bricklayer … Or? Was I being compared to an illegal immigrant? I was very mindful not to bad-mouth any physician to any patient. I hope you return the courtesy. I’m sorry you are having such difficulties. Thanks for your time.

    • Suzi Q 38

      “..It’s similar to what happen in the 1990′s when illegal immigrants
      were replacing union bricklayers. Why? Because they were easy to
      substitute and are cheaper to pay!”

      NP’s are not illegal immigrants.
      Doctors are not union bricklayers.

      Your analogy is stupid. I refuse to explain myself. May Wright does a much better job. Please read her post 5 times.

      • Anthony D

        (-_^)

      • Anthony D

        That’s your opinion and I respect that and I’ll stick to mine as well!

        • Suzi Q 38

          I do apologize Anthony.
          Please understand that I am NOT implying that you are stupid.
          I felt that your analogy was “stupid.”

          JMHO.

          Yes, you are entitled to your opinion.

          • Anthony D

            Understood! (*_^)v

  • buzzkillerjsmith

    Leave aside the MD-NP cagefight for a moment and focus instead on Dr. W’s statements that we need teams to manage populations.

    This, it seems to me, is where the whole edifice comes crashing down. I, and thousands of other docs like me, simply do not want to manage populations. We want to see sick people one on one. This is not to say that population health management, to the extent it can be done, is not an important and worthy goal. But it is a full time job, a job that we physicians are certainly qualified for, but it is a full time job, not something that can be done in our free time.

    It seems to me that those who are imaging our perfect future jobs have little realization that thousands of us, perhaps tens of thousands of us, will refuse to do that job or will do it in a manner that will be less than pleasing to our overlords. And what are they going to do? Fire us? Good luck getting replacements, with any professional qualification. And we’ll just skip on to the next job.

    And what about the med students? I suspect they too will be less than thrilled.

    What could change the calculation? Lots and lots and lots more money for us , as well as a promise from American society that we will not be replaced to save a few bucks. If you believe that is going to happen, I have some real estate to sell you.

    • southerndoc1

      “And what about the med students? I suspect they too will be less than thrilled.”
      Oh, but they’ll realize very quickly that the derms and rads aren’t expected to do this, it’s only the primary care docs who are spending their nights and weekends in front of a computer screen fluffing their patient registries. And the criminally clueless AAFP thinks this is going to save family medicine . . .

    • https://www.facebook.com/arobert6 Alice Robertson

      Buzz…I like your posts…I do so like them…but I like literary criticism and I really think one of doctor’s weakest points is their dire predictions of some supposed doctor shortage with gloom and doom predictions. Healthcare is a very good choice as far as job stability, etc. I know…I know…the differentiating between doctors (who used to run the show, but a segment of your colleagues really messed up your futures and your very role in the grand scheme). I know doctors are quitting, etc. and that’s a real shame but wherever a need exists capitalists or the government find a way to fill it.

      Patients read these threads and think…why does my doctors hire an NP if he feels this way? The obvious answer is the doctor will make money by making more per hour than he pays her. And yes an NP is limited by her very training that is not up to par with your own. And quite frankly as much as I like NP’s there is some truth in the fact that overall they are treating the mundane things that we already know half the time didn’t even require a doctor visit. Which only makes patients grateful they can see them that day because we are trained to think we need a doctor for everything and when the doctor can’t handle all the visits patients like that an NP is available.

      So I asked a med student about the dire predictions. The answer was if you aren’t a minority there will be more applications to getting into med school than there are seats. Medicine in all vain glory and sacrifice will allure people to the field. The quality factor with the heavy reliance on MCATS is problematic but some say sufficient on many realms. But somehow (as much as I dread and disdain Obamacare which years ago on this blog was a nauseating word as doctors defended it and if you tried to enlighten them you were scolded for using the word….I still think people want to practice medicine…which again I know is a bit subjective).

      I guess this is a rant and an appeal because while I learn from posts like yours, the continual doom-and-gloom warnings about shortages are coming off as a type of “Don’t say I didn’t tell you so!” And I fear in ten years these posts will remain and patients will look back and say, “What the hell were they talking about?” Ha!

      I just wrote a post last night about patient bullies because they are bloody well boring too. It’s a bothersome phenomena:) Your posts are too good to resort to this, just as I wish I had time to go back and delete some of my mad as hell at doctor posts over my daughter’s doctor mess up (they weren’t my best….but it’s all relative I guess:)

      • buzzkillerjsmith

        Medicine is not in fact a great job, Alice. It’s actually a pretty crappy job , truth be told. Curious how few non-physicians seem to understand this in spite of massive communication of this simple fact. In actual fact we have the highest burnout rates of any profession with comparable educational levels. Our suicide rates, especially among women doctors, are astronomical.
        People who go into medicine have other options given their academic qualifications and cognitive gifts. That’s the reality. Large numbers of us would not go into medicine again.
        My electrical engineering buddy with four year of education earns almost as much as I do with 11. Where the hell did we go wrong?
        As far as the gloom and doom, in a year or two, don’t say I didn’t tell you so.

        • https://www.facebook.com/arobert6 Alice Robertson

          I get your post but not your dismissiveness. I don’t know Buzz…my friend sent me some stuff from physician only boards and I was a bit floored at the level of whining about patients. It was sorely discouraging…and maybe it clouds my judgement. It feels like a waste of time to even try to share with some doctors here that their job is worth it. For a segment nothing short of arse kissing will help and some here are willing to do just that if their job depends on. It’s the plus side of not being a doctor nor having any skin in the game, nor fear of being dismissed.

          So I up and ask some of the doctors at the Clinic (no easy job for them). They roll their eyes at some of the comments they read here, so your proclaiming my job status title as leaving me a bit ignorant isn’t really helping. But again you remain anonymous so what the hell….you may as well rant in disguise.

        • eddy

          Nicely stated.

      • Dr. Drake Ramoray

        It is true that there are many more medical school slots than applicants, but the quality of physicians will go down. We have had fairly high turnover at the two hospitals nearby and with each successive replacement the quality of the physicians get worse. My consults this week so far have been.

        1.) Evaluation of hypothyroidism as a cause of a paitent’s heart failure by a new cardiologist (to the hospital, in practice for ten years). In a patient who actually had a high free thyroid hormone (because of the heparin that the cardiologist was giving the patient).

        2.) A new diagnosis of diabetes by an oncologist that is new to the area. A1c of 7.7 on a regular diet, drinking soda in the room, with blood sugars ranging from 150-210 . The diabetic control of this patient is probably better than 2/3 of the hospital at least.

        3.) A new OB who consulted me on abnormal thyroid function studies which were all abnormal because the patient is pregnant. An OB who doesn’t understand basic thyroid physiology in pregnancy. (This patient’s TSH is low because of the HcG effect from early pregnancy and her total T4 is high because of the increased estradiol production from pregnancy.) She appears euthyroid and her Free T4 (the true measure of active hormone in most cases) is normal. Hyperemesis is a known and well documented cause of suppressed TSH levels.

        There is probably not a shortage of doctors in this country. There is a shortage of primary care doctors in this country. And there is certainly a shortage of competent doctors in this country. Nothing in the pipe is going to improve the quality or the quantity of primary care doctors.

        • Guest

          I blame it in part due to the type of training new physicians go through. I am seeing this phenomenon too, though occasionally an outstanding clinician will appear. Most of the time they are technically and intellectually clueless and seem to lack insight into that fact.

          Our best physicians are those in their 50s. They are intellectually quite talented and still have the stamina to work hard. They also have tremendous work ethics. The younger folk tend to be not bright and not hard working.

          • https://www.facebook.com/arobert6 Alice Robertson

            Well to give hope to the reader at Cleveland Clinic the residents are impressive. Now how that will change afterwards I am clueless, but right now they are excited…some are brilliant…but for whatever reasons (good training? Fear?) they do backflips to please the patients and they like conversation and the personal aspect. When we discuss with them 90% of the time it’s pleasant and most of them really listen well. So there’s hope:)

        • https://www.facebook.com/arobert6 Alice Robertson

          Well Drake that’s a more reasonable response than other responses here. What patients want is to learn…they long to understand how to get better care (realizing few patients will post here as I do. I have friends who are doctors…hate Obamacare but love their jobs, and I live in the medicinal system…so maybe that makes me jaded:)

          It’s understandable that Buzz and others are commiserating over lose of income. Many, many posters here are suffering lose of income (hasn’t income went down for the average household by 4% under Obama, and 10% for minority households (it was in the WSJ recently…maybe Steve Moore)? My husband’s income was cut by 40% for ten years until 2011 when it started to go up again, so it’s not a lack of empathy. My post today was more of a plea because just as doctor’s tire of their nose being held to a standard that seems almost unattainable…patients almost need to read that doctors care beyond a paycheck (it’s not that the paycheck isn’t important..but it is important for everyone out there).

          But if hindsight is 20/20 we see that a segment of doctors who posted quite boldly about how great Obamacare would be and they licked their chops wildly in anticipation of future single payer because of the steady paycheck it would evoke….we’ll we see if they were ignorant, misguided and single-minded.

          The only answer is in the legislature and this board is going to be a
          poor place to accomplish that if the patients feel their opinions matter
          not (meaning patients vote in much larger numbers than doctors by sheer logistics). If doctors post in reactionary tones to patients what do they possibly hope to accomplish? That patients will feel empathy for them and tell their reps to get rid of Obamacare? Not likely. Doctors would do a service to themselves and their patients to put a lid on their continual warnings of gloom-and-doom that patients often view as self-serving. Turn your energy into a type of persuasive writing as you did here. You are going to need patents to care about your craft enough to be persuaded into caring enough that you don’t have them rolling their own eyes at dire warnings.

        • rbthe4th2

          Most unfortunately sir, this I’ve found to be true also. I’ve had some docs and I’ve found the medical answers before they did. The worst part is that I know how to read a lot of medical, peer reviewed literature. I can see who knows what. Not only is it that, but I find that they don’t want to look for answers. The third worst part? If the computer says the labs are fine, then all is fine. They judge the paper, not the patient.
          Good luck sir! We’re all going to need it.

      • querywoman

        Hey Alice, I’m with you. No doctor shortages are looming; people still want in med school.
        More people go to college than in our parents’ time.
        Americans want in colleges to learn many professions very badly! Each high school graduates a certain percentage of kids who are reasonably high achievers who want to be things, like doctors and nuclear physicists. Doctors can still get American jobs, but many Americans with degrees in other sciences find that jobs are going to English speaking Africans and Indians who work for less money.
        I do not agree with Dr. Drake that the quality of doctors will go down.
        I would like to see the length of medical training shortened some. I’m longing for a return to simpler, intuitive medicine that’s less technology mad.

        • https://www.facebook.com/arobert6 Alice Robertson

          Um….last I heard Dr. Welby was drinking the same juice as Dr. Jekyll…poor guy went off the deep end! Ha! Oh just having fun….trying to make you laugh at my dramatics!

    • Dr. Drake Ramoray

      Buzz. You have the diagnosis right but your treatment is not accurate. The money part is only part of the issue.

      Yes, payment is an issue. Medicare has recently decided to cut the reimbursement for an ultrasound guided thyroid biopsy by 50% (you read that correctly… half) starting this January. Currently an ultrasound guided FNA in our office costs $2-300 while down the road at the hospital is costs $6-800 dollars with facility fees. We are actually discussing at our next meeting whether or not it’s even worth it for us to do biopsies anymore (take 40-60 min) and doing them instead of seeing patients will now be a money loser as we could make more money just seeing patients.

      I don’t lament the loss of money all that much as currently we probably were losing a little money for the time spent anyway. The problem is we are due for a new machine and by ceasing to do thyroid biopsies I have lost more autonomy. In my experience in the past radiology doesn’t do as good a job. They don’t always biopsy the right nodule. The patient has to wait to have it scheduled at some unknown time in the future. The physician performing the biopsy is not the same person following the patient longitudinally. Radiology departments make patient’s go through ridiculous requirements to have the procedure, npo, no aspirin or coumadin, and they must have a driver, none of which is a requirement for any Endocrinologist or according to the American Thyroid Association. I’m not even gonna bother trying to cover radioactive iodine treatments at the hospital by nuclear medicine physicians and i have commented on bone density imaging on previous posts.

      The issue with primary care, and medicine in general is the loss of autonomy. I honestly don’t foresee private medicine (outside of concierge) lasting for more than 10 years, probably not even five. My group is in the process of contracting with a clinical research firm because it is abundantly clear that we cannot maintain any semblance of autonomy without some alternative source of revenue. Since none of us want to do Bo-tox or run a physician run diet program, research appears to be the best option.

      As much as I hate the above change to our practice, and the uncertainty that we can provide complete services to our patient’s (we are about due to replace our ultrasound) this still doesn’t bother me as much as the prior authorizations for diabetes medications, the physician to physician phone calls required by insurance companies for patient’s who I suspect have a pituitary problem (what do you think the chances the person on the other end of the phone is an Endocrinologist), having to get approval for nuclear medicine imaging in patient’s who have thyroid cancer.

      I’m more upset that we may have to outsource our thyroid FNA’s than I am that we will get paid less for this. Looking at things from the other side is also true. You could double my take home pay tomorrow and I”m not sure that would keep me in this profession with the way things are headed. Between meaningful use (especially stage 2) and the above issues it’s becoming more bureacratic and leaves less and less time to take care of patients. Perhaps with the increase in pay, my practice wouldn’t be looking into doing research, but I don’t think it would improve my outlook on taking care of patients.

      Not that it wouldn’t be nice, but more money for doctors is not gonna fix medicine.

      • buzzkillerjsmith

        Thanks for the info. I guess I should state that my analysis only applies to my world, primary care.

        In that world autonomy and relative freedom from hassles are direction functions of income, y=mx+b. The more you earn, the fewer patients you have to see, the less paperwork drag you have, and the more folks you can hire to do the dirty work. I agree that bringing the money home is often not the main thing. I should have been more clear about that.

        Fortunately I don’t have to do many doc to doc calls, but a few are enough. They’re a nightmare. Also as a consultant, you are probably not at liberty to cap your practice lest you piss off your referring docs. Correct me if I’m wrong about that. But we PCPs can cap the practice if we want. And if we get more money per pt, well you know the rest.

        • Dr. Drake Ramoray

          I cannot speak for my other specialty colleagues but the Endocrine formula for reimbursement is not terribly different than your formula for primary care. Especially now that we don’t really gain anything from DEXA scans (except better care) or ultrasounds (except better care) and now probably biopsies (except better care). Nuclear medicine is maybe still safe for awhile. With the absence of consult codes from Medicare and the continual reduction in reimbursement for imaging studies and procedures I’m actually not terribly different than primary care especially for diabetes. I don’t see much more than the E & M charges plus any labs I may be able to do in house. That being said I only have to deal directly with a 1- 4 problems of the 15 point problem list.

          I think the push back in our community would be too great should we stop seeing medicare (an option if our research arm takes off). But the bigger threat is that if we did so one of the hospitals would try to bring in their own Endo, so there is a political side to the financial calculation.

          We generally don’t cap off our practice although we do have the ability to a degree since there aren’t very many of us. We don’t currently see medicaid (unless pregnant) and the patient’s often disappear after delivery anyway (only to return when pregnant again). Medicaid pay in my state isn’t bad but when our office manager showed us she has 5-6 denials and appeals for services (especially ultrasound and imaging) to get paid we just stopped taking Medicaid in the absence of pregnancy or phone request by the referring provider.

          As all of the MD’s in our office have fairly mature practices, we are an under represented specialty, have a niche role (see above comments as ultrasound, FNA, and nuclear medicine that all require additional money and training beyond fellowship (nuclear medicine is not offered at any fellowship program i’m aware of), and many new grads want stable hours and stable pay, we have had some trouble adding another doc. Our relatively rural location probably doesn’t help either.

          We recently added a PA to help with a lot of the diabetes and other cases that don’t require as much in the way of advanced services. She has a good long experience in FP and emergency medicine (surprise she doesn’t want to do primary care either) and places Testopel better than the docs (we don’t bother doing them anymore). Other than thyroid FNA I haven’t done any minor procedures in over ten years.

          There has always been an under-representation of Endocrinologists and as we get reduced to a higher percentage of pay from E&M charges we are increasingly becoming familiar with the plight of the primary care doc.

          In our camp at least, AACE is not as clueless as AAFP, although 6,000 docs isn’t a very loud voice and I doubt AACE will be successful in reversing the ultrasound reimbursement changes. Not many people go into Endocrine, when I was in training not all the fellowships even filled, because it’s 2-3 years of extra training and you could make a lot more if you put that training towards another internal medicine specialty.

          • https://www.facebook.com/arobert6 Alice Robertson

            When Teddy Roosevelt said sometimes the capitalists need policing how could he have imagined a lopsided world where the government is often worse than the capitalists?

          • buzzkillerjsmith

            Thanks for sharing your experiences. We too mainly make a living off of E & M codes, but do have a fair number of procedures: cryotherapy, benign and malignant skin lesion removal, IUDs, subq contraceptives, splints, casts, lac repair. We also give IV therapy in the clinic, for dehydration and TNF-alpha inhibitors and such. We also give allergy shots and have not yet had anyone die, although we do use epi from time to time. Peak flow, spirometry, EKGs of course. So we have a few procedures. I could use me some more wart cases, if you know what I mean.

            My neurology buddy is in a bad way. Neurology, as you know, is mostly and E & M specialty. He also works in rural CA and has more than his share of Medi-Cal, and his older partners, sweet guys, all retired on him–except that they didn’t really but rather skimmed all the cream from the practice by taking all the sleep cases and the rehab rounds. Apparently those pay.

            So your experience jibes with what I have heard with other non-procedural subspecialists. Don’t know much about rheum, maybe you do. Have you considered a gi fellowship?

          • Dr. Drake Ramoray

            I don’t have any figures but I have also heard that sleep medicine pays very well. I think that sleep studies themselves is what pays because the docs around here have no interest in any chronic care and just do the sleep study and then push them back to the referring docs.

            Rheumatology made most of their money off of infusions. As such, like Oncology they took a big hit under Bush 43 when they cracked down on infused medications several years ago. I know a Rheum doc that had to stop giving Humira because Medicare started reimbursing about the same as it cost to get the medication. Now the hospital does it and makes thousands on giving the same medication.

            We have the same problem with Reclast for osteoporosis. If we give Reclast in the office it is at a loss. Just down the road the hospital makes $2500-$3500 because of their billing and facility fees per infusion.

            If Medicare was slashing price across the board that would be one thing, but what happens is that it is actually paying more just to big hospitals instead. Why Medicare, and really even the private insurers, have let this happen I’m not sure. While we don’t lost money on ultrasound and DEXA imaging, the hospital collects 3-5x as much as we do. If there is something abut physician reimbursement that irks me this would be it (as opposed to outright saying I should be paid more).

            I can provide a service at below hospital cost, often several times over, but third party payers keep slashing reimbursement to providers but allow crazy facility fees. In some cases the reimbursement becomes so low that I lose money providing that service. Meanwhile the hospitals make a killing.

            A new ultrasound machine costs 20-30k off the shelf without accounting for supplies and maintenance. As you can imagine we have to think twice about replacing our machine if Medicare is gonna cut reimbursement for a procedure by 50% in less than three months.

            My group will try as hard as we can to remain independent, even if that means devoting a significant amount of time to clinical research. Does that mean there will be some loss in availability to the community for patient care, probably. Beats working for a hospital though, been there, done that, not again if I can help it.

          • buzzkillerjsmith

            Thank you very much for the info. I’m sure you and I agree that the facility fees are a pox on the human race.

  • Anthony D

    “The NP vs MD debate”

    When Robert F. Kennedy was shot and was dying on the floor in The Ambassador Hotel in Los Angeles, they were screaming…….”is there a doctor in the house?”.

    They sure as heck weren’t looking for a Nurse Practitioner that’s for sure!!!

    • Suzi Q 38

      True, but in the end, even a team of doctors, surgeons, and nurses could not save him.

      • valerie saenz

        There was a head/brain GSW.

    • querywoman

      How many of us will ever get shot? Too many already!
      Most of us need less dramatic routine medical services.

    • a dn

      An NP would also have responded and I hope not looked around to ask a doctor what to do first. And I know too, that EMTs are far better at emergency care than doctors, even those who’ve worked in emerg.

      There’s nothing a doctor does that an NP cannot do, and little that a doctor does today that is practising medicine. Rather, practising business.

      When did doctors stop assessing with their hands, ears and eyes? When someone invented the MRI, and they invested in it.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Let me suggest that there is an even bigger picture here. Leaving aside the cat fights between MDs and NPs, as buzzkillersmith wisely suggested, the problem being created now is one of institutionalized disparity.
    If insurers make it acceptable that a Pareto version of primary care can be delivered at some nominal savings, then a bunch of “narrow network” plans will be created where members can only be assigned to an NP PCP (maybe even a grocery store type of practice), and those “health plans” will be “offered” to certain populations only.
    I have a huge problem with that…

    • buzzkillerjsmith

      Absolutely. But of course that’s the model. Narrow focusing to maximize profits is what smart businesses do. I suspect they teach them that in Business 101 but am not really sure. Who can blame Walgreens for taking advantage of an opportunity?

  • artful

    The universal non-ending supply theory, argues that one doctor or nurse is really two!
    If you take a nurse out of the inelastic supply of nurses, even if that is a NP, there is one less nurse. Or if a nurse that is 65 as many more are nearing and she retires or choses to work part time, that takes a nurse out of the supply. The same is true of PA’s whatever they may be, they have had to be a nurse or something like a nurse before.
    If you look at what PCP’s do and compare it with what a NP does, from a patients prospective, it is the same and not too difficult to do. What the patient has made the appointment for is not to have the PCP cure him or her, but rather to get a 1, 2, o3 3 pieces of paper from what previously was called his “gatekeeper”.
    Piece 1, is most often a prescription refill required each year for an existing maintenance drug, plus if not,
    Piece 2, a lab tests, to gauge his blood vitals to see if they have an infections and if so which antibiotics work best, or
    Piece 3, a referral to a specialist, that the patient knows he or she will be sent to, because the PCP is after all just the gatekeeper.
    But NP’s and PA’s are too skilled they say to be gatekeepers and too busy to go to school, or too busy with their families to do so, so let them practice as specialists and earn the big bucks. After all they have watched their specialist doctors for years and have real OTJ skills.
    So why not make getting a lab test up to the patients, and drug prescriptions up to Pharmacists who after all are doctors too, and from these two sources get referrals to the specialists they need.
    Patients aren’t what they used to be either! They can even think too!

    • Steve H.

      I’m not sure that medical marijuana is really such a good idea.

    • valerie saenz

      “So why not make getting a lab test up to the patients”. And what health care professional is going to interpret a lab value that he/she did not order? What GOOD IS a test without interpretation? Often, patients will ask for a test they think they need. Let’s say a woman decides she needs a CA125 because she has just read a news story about an actress who died of ovarian CA. The woman can order her own lab test, then gets a value/result she cannot understand. What happens?

    • Kristy Sokoloski

      The patients have no idea just how hard of a job it is that the PCPs do on a regular basis when it comes to the care of patients with complicated medical histories. There’s a lot of work involved that most do not realize and because of that they think “oh this is the easiest job on the planet”. I have spent time in a PCP office when I crossed the other side of the healthcare fence to do an externship for Medical Assisting. And that time as well as back in January when one of my relatives had to be in the hospital for about a week when I watched her PCP come in to care for her at 9:00 at night (yes, you read that right). Her doctor had a very long day but yet he came in after his long day at the office to take care of her. So anyone who thinks that the job of a PCP is super easy is sadly mistaken. I would love to see you spend a month following them around so that you can see what really goes on with their job, and no it’s not just about paperwork that comes with the job. There are people out there that need actual Primary Care Physicians to take care of them and their medical history. My relative, and a good number of my friends fall in to this category.

  • a dn

    In response to the question here “How can they do the same work as well as we do?”

    I would say, they can’t do the same work you do. That’s why patients want them.

    Among other things, where they are in charge without having to ask a doctor’s permission and pretend he has superior knowledge, NPs (primarily women, still) practise medicine, not a rotation through the latest drugs, treatments and surgical interventions which are largely unproven and profit motivated.

    I wonder how many of you have had NPs and similarly trained nurses as your primary or sole healthcare provider? I have, and know that they are preferred by their patients, to a one.

    “How,” some primary care doctors ask, “can someone with significantly less training, and very different training, do the same work as well as we do?”

    • Kristy Sokoloski

      I am a patient that doesn’t want an NP taking care of me. And there are a few others on here that have voiced that same sentiment. That’s why it’s good that the patients get to choose who they want to see: a physician, or an NP.

      • painslayer

        hey, no hard feelings, kristy. but do accept this: please do not bother paging me at 2 a.m. when i am on-call for the group. wait until the following morning and have your favorite md/do call in your “emergency” dose of vicodin (or ativan or flagyl or whatever).

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