How non-physician practitioners are pawns of large health care organizations


During our family trip to Walt Disney World this past year, we got the Disney Dining Plan. It turned out to be a lot of food. On the last day of the trip, we each still had two sit-down meals and about five snacks apiece to go through. Needless to say, we ended up leaving with a bunch of soda and cheap candy and still felt sick from all the snacking.

Disney veterans will be quick to point out that we used our dining allotment incorrectly; a quick search on the internet yields hundreds of great articles about Disney Dining Plan strategy, meant to maximize the quality and volume of food consumed. The guiding principle here is that the plan is only worthwhile if you are able to consume a greater value than the upfront cost; opacification of the downstream costs gives Disney a chance to profit when unwitting consumers (like myself) use their valuable snacks on bottled water or bags of cheap candy on the way out of Epcot.

Consider my experience a valuable warning, because, in a way, I never left Disney, and neither did you. We are all, in some way or another, participants in the Disney Dining Plan for health care. In the United States, every consumer – whether by premiums, taxes, or opportunity costs – bears large upfront expenses earmarked for their health care. Per capita, citizens of the United States pay more for health care than citizens of any other country – our dining plan is the most expensive. And yet, for a number of reasons, we tend to, figuratively, end up eating bagged chips and cheeseburgers far more often than steak and chocolate fondue. Obfuscation of the downstream costs keeps the consumer in the dark and effectively shields health care from the benefits of market economics. Just like being at Disney, the system is built to take your money, and it takes a savvy consumer to prevent that from happening.

In particular, one are where American health care consumers are being fed cheeseburgers over sit-down meals is in the use of non-physician practitioners (NPPs) – for instance, PAs or NPs. Importantly (and before jumping to a knee-jerk response), NPPs are excellent, many are just as smart as physicians, they are valuable, and they certainly have a place in health care. Also, I love cheeseburgers. However, they (NPPs – not cheeseburgers) are not doctors. They are not taught like doctors, they do not undergo standardized, supervised training like doctors, and they do not practice like doctors. They are not experts in their fields, and the buck does not stop with them. Many got their degree exclusively online. If a celebrities or elected officials are hurt, they do not go to the world’s leading nurse practitioner. NPPs do not lead inpatient treatment teams. They are not world-renowned surgeons or diagnosticians. And none of these things are failings on their part.

Medical training is hard and time-intensive. Not everybody wants to spend the time and effort to become an expert in their field; that doesn’t mean that every- or anybody else is worth less for not making this very personal choice.

But, while an individual’s worth may be independent of their expertise, their medical care is highly dependent on their training. Consider the number of individuals who participate in a patient’s medical care: a patient care tech, nurse assistants, physical therapists, respiratory therapists, nurses, NPPs, physicians, etc. Each of these categories of people contributes valuably to patient care and requires different amounts of training. But, as it is clear that one must rely more on the expertise of their physician than on that of the patient care tech, it should be equally clear that physicians and NPPs are not equivalents.

However, confusing and poorly executed health care policy has created a system that rewards specific profit-motivated behaviors, causing proliferation of NPPs. A five-minute visit can be billed the same as a fifteen-minute visit; consequently, visit times grow shorter. A relatively simple medical encounter can easily be billed higher than a time-intensive psychiatric encounter; consequently, good psychiatric care is hard to find. And care delivered by NPPs is, in most circumstances, reimbursed identically to care delivered by physicians. However, the expertise differential means that employers are willing to pay less for care delivered by NPPs, which means that they are able to take home a larger share of the profits at the end of the day; consequently, care delivered by NPPs is much more common, and care from experts is now harder to find.

Think back to the dining plan. Disney benefits when sit-down reservations are scarce, and consumers end up settling for junk food over filet mignon. As a result, they work hard to sell you sodas, chips, and candy over steak.

The same is true for health care. Larger companies, seeking to benefit from the cost-savings of hiring NPPs over experts, seek to have patients accept care by NPPs as equivalent. Because health care costs are paid upfront and then hidden on the back-end, consumers accept this sleight of hand without realizing that the care they have already paid for is being substituted out for a cheaper alternative. Consumers forget that they have already paid to see a medical expert. This, in turn, makes it harder to get care from the experts as this more expensive option is made inaccessible. Getting in to see your primary care doctor can often be tougher than scoring a reservation at Cinderella’s Royal Table.

And while the greatest injustice is surely that of consumer fraud, the NPPs themselves suffer a nearly equal injustice in that they have become oft-unwitting pawns of large health care organizations, poised to take advantage of the fact that the NPPs don’t realize their own monetary worth.

Physicians must demand better care for patients because patients deserve expert care. NPPs must demand organizational transparency if they are to be treated like medical workhorses. Consumers must demand their money’s worth through cost and training disclosure.

And we all must demand a better dining plan. And more chocolate fondue, please.

Tom Belanger is an emergency physician and CEO, DRPLZ.

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