The health care turf battles: It’s time to work together

MedPage Today recently tackled a very controversial issue in medical practice.  The piece explored the ongoing battle between dermatologists and allied health professionals (AHPs) over the performance of dermatologic procedures.  As independent NPs and PAs begin to bill for more and more procedures (thus potentially talking revenue away from board certified dermatologists) specialists are beginning to argue that the AHPs are practicing beyond their scope of practice.

According to the Journal of the American Medical Association, nearly 5 million dermatological procedures were performed by NPs and PAs last year.  This has dermatologists seeking practice limits, ostensibly to protect “bread and butter” revenue streams from biopsies, skin tag removals and other common office based interventions.

First of all, I want to say that AHPs are essential to providing care in the era of the Affordable Care Act.  NPs and PAs are able to help meet the needs of underserved areas and do a remarkable job complementing the care of the physicians with which they work.  With the rapidly expanded pool of newly insured, as well as the increase in administrative tasks (electronic documentation) assigned to physicians, AHPs must help fill in the gaps and ensure that all patients have access to care.  In my practice we are fortunate to have many well qualified AHPs that assist us in the care of our patients both in the hospital as well as in the office.

We must remember, however, that physicians and AHPs have very different training.  Each professional posses a unique set of skills and each skill set can complement the others.  Many of us in specialty areas spend nearly a decade in post MD training programs and learn how to care for patients through rigorous round the clock shifts during our residency and fellowship years.  In addition, we spend countless hours performing specialized procedures over this time and are closely supervised by senior staff.

Most AHPs, in contrast, do not spend time in lengthy residencies and often have limited exposure to specialized procedures.  Turf battles have existed for decades and are certainly not limited to dermatology; nor are they limited to MDs and AHPs.  In cardiology in the late 1990s, for instance, we struggled with turf battles with radiology over the performance of peripheral vascular interventions.  In many areas, these battles resulted in limited availability of specialized staff to patients and a lack of integrated care.  Ultimately, the patients were the ones who suffered.

Fortunately, in the UNC Health Care system where I work (as well as others across the country), we have taken a very different approach.  After observing inefficiencies and redundancy in the system, several years ago our leadership decided to make a change.  The UNC Center for Heart and Vascular Care was created; vascular surgeons, cardiologists, interventional radiologists, and cardiothoracic surgeons, all working under one cooperative umbrella.  Patients are now discussed and treated with a multidisciplinary approach.  Electrophysiologists and cardiothoracic surgeons perform hybrid atrial fibrillation ablation procedures; vascular surgeons and interventional cardiologists discuss the best way to approach a patient with carotid disease.  All working together to produce the best outcome for each individual patient.  We have seen patient satisfaction scores improve and we have noted that access to multiple specialty consultations has become much easier to achieve in a timely fashion.  Most importantly, communication among different specialties has significantly improved.

Unfortunately, with the advent of the ACA and decreasing reimbursement I suspect that turf battles will continue.  Financial pressures have become overwhelming for many practices and the days of the private practice are limited; more and more groups will continue to “integrate” with large hospital systems in the coming years.  Specialists such as dermatologists and others will continue to (rightly so) protect procedures that provide a revenue stream in order to remain financially viable.

However, I believe that our time will be better spent by working together to improve efficiency of care, quality of care and integration of care.  NPs and PAs are going to be a critical component to health care delivery as we continue to adapt to the new (and ever changing) ACA mandates.  We must put patients first; turf battles and squabbles among health care providers will only limit our ability to provide outstanding, efficient care.  Let’s put the most qualified person in the procedure room, and make sure that ultimately patients get exactly what they need.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • QQQ

    “as we continue to adapt to the new (and ever changing) ACA mandates.”

    In 1980 the cost of health care was 1110 per capita [ including health ins,], in 1990 it was 2600, in 2000 it was 4550, in 2010 it was 8402, and by 2013 it was 9810. [source: statistic brain] That means that the rate of inflation for health care from 1980 to 2013 was 883%. The overall rate of inflation from 1980 to 2013 was 283% [ source: bureau of labor statistics]. During that same period of time health care has gone from 9% of GDP to almost 18%. The real problem is the cost of health CARE, not health insurance. Health insurance premiums are a reflection
    of health CARE costs. If we don’t find the reason for skyrocketing health CARE costs, no insurance program the ACA anything else, is going to make a difference. HINT: could it be the 1986 EMTALA legislation?

    • Dorothygreen

      This is an old post but I just had to reply to QQQ. The reasonS for US extraordinary health care costs are known – have been for quite some time. Even as far back as the late 1980s via Paul Starr’s Book – Socialization of American Medicine – the rise of a sovereign profession and the making of a vast industry. Further, Rosemary Stevens – In Sickness and in Wealth. Now, that kind of sums up where we are today – except it got worse. Price Waterhouse Copper http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml calculates health care waste to be 1.2 trillion of the 2,2 trillion/annum costs and breaks it into 3 major categories

      1. Behavioral – individuals who have lifestyles that lead to chronic preventable diseases. That’s the majority of the US to some degree or another. I would further add that this waste is driven by Big Ag, Big Food and even some organizations who are making money on the USDA so called plate.

      2. Clinical – Many, many articles about this waste, abuse, overuse etc. in this category.

      3. Administration – That would certainly include insurance companies (at least pre ACA) and hospital administrators etc.

      Further, a significant percentage of physicians, hospital CEOs and others in health services are in the top1%. PCPs and others are more in the middle. There is inequality at many points in US health care.

      But, this does address the issue of NPs, PAs doing minor procedures, even acting in the capacity of a PCP in some places on their “limited” education. Well, perhaps our model of medical education needs reform. Nurses and PAs start learning medical related issues early in their post high school education whereas physicians post high school can be varied. Most other countries have a ladder for those entering medicine. Bottom same for all, move up the ladder – get off at one level or another to do what it takes for that level of expertise. Those who want to be physicians go on. We can learn much from the experience of other rich countries about many aspects of health care (not just Canada or UK) – most of which have overall better health care indicators at half the cost.

    • Dorothygreen

      This is an old post but I just had to reply to QQQ. The reasonS for US extraordinary health care costs are known – have been for quite some time. Even as far back as the late 1980s via Paul Starr’s Book – Socialization of American Medicine – the rise of a sovereign profession and the making of a vast industry. Further, Rosemary Stevens – In Sickness and in Wealth. Now, that kind of sums up where we are today – except it got worse. Price Waterhouse Copper http://www.pwc.com/us/en/healthcare/publications/the-price-of-excess.jhtml calculates health care waste to be 1.2 trillion of the 2,2 trillion/annum costs and breaks it into 3 major categories

      1. Behavioral – individuals who have lifestyles that lead to chronic preventable diseases. That’s the majority of the US to some degree or another. I would further add that this waste is driven by Big Ag, Big Food and even some organizations who are making money on the USDA so called plate.

      2. Clinical – Many, many articles about this waste, abuse, overuse etc. in this category.

      3. Administration – That would certainly include insurance companies and hospital administrators etc.

      Also, a significant percentage of physician specialists, hospital CEOs and others in health services are in the top 1%. PCPs and others are more in the middle. Prices are determined by them, not negotiated (except medicare) with representatives of “we the people” There is inequality at many points in US health care.

      But, this does address the issue of NPs, PAs doing minor procedures, even acting in the capacity of a PCP in some places on their “limited” education. Well, perhaps our model of medical education needs reform. Nurses and PAs start learning medical related issues early in their post high school education whereas physicians post high school can be varied. Most other countries have a ladder for those entering medicine post high school. Bottom same for all, move up the ladder – get off at one level at a level of expertise needed – physicians at the top, We can learn much from the experience of other rich countries about many aspects of health care (not just Canada or UK) – most of which have overall better health care indicators at half the cost.

  • JR DNR

    I went to the store and was surprised to see a kit to burn off your own warts with dry ice. I am not sure I’d want to use dry ice on myself without training or guidance.

    Yet… do people really go to the doctor to remove skin tags instead of doing it at home themselves? I guess I have a hard time thinking skin tag removal should be limited only to dermatologists and not family doctors, internists, PAs, or NPs.

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