Time to unleash nurse practitioners and physicians assistants?

Discussion in 'Too Hot for Swamp Gas' started by Row6, Aug 16, 2013.

  1. Row6
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    Row6 New Member

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    An opinion piece from Wonkblog:

    :A crucial change in the health-care conversation over the last few years has been the shift in focus from “costs” to “prices.” Everyone knows American health care costs too much. But after the release of the International Federation of Health Plans’ data and Steven Brill’s epic Time article and the New York Times’ massive price series, it’s also becoming common knowledge that a major cause of those high overall costs is sky-high prices for every individual service, drug, and treatment.

    Identifying the problem is easy. Doing anything about it is hard. But there’s one thing states can do that isn’t particularly hard: Allow more nurse practitioners — who charge much less than doctors — to treat patients directly, without a physician’s oversight.
    Doctor’s groups oppose this strenuously. They say patient safety is at risk. What’s really at risk is their incomes. 17 states and the District of Columbia already allow nurse practitioners to treat patients directly and there’s been no resultant rash of patient deaths in Washington, Oregon, Maine, Colorado, Arizona, New Hampshire, Vermont, Rhode Island, Montana, Idaho, Nevada — I could go on. (Nor, by the way, has anyone heard of doctors going begging on the streets in those states, but I digress.)

    The Wall Street Journal reports today that five other states are considering freeing nurse practitioners to practice with physician oversight, including California, where only 16 of the state’s 58 counties have enough primary-care doctors. These kinds of shortages are common, and they’re likely to get even worse as the population ages and the Affordable Care Act expands coverage to millions of Americans.

    Doctors don’t have a good answer for how they can rapidly expand to meet all this new demand. But they know they don’t want nurse practitioners doing it. The powerful California Medical Association — also known as the doctor’s lobby — opposes the bill with the usual line: It will “ultimately harm patients and decrease quality of care.”
    No, what will ultimately harm patients and decrease the quality of care are too few doctors who charge far too much. But right now, those doctors are the incumbents, and incumbents are politically powerful. They’ve persuaded the California state assembly to amend the bill so it “would allow NPs to operate independently only in a hospital, clinic or other group setting and eliminate a pathway to autonomous practice after 6,000 hours of supervised work.”

    Bringing down national health-care costs will be hard. A lot of the calls will be wrenching, and the evidence on both sides will be close. Not this one. As the Institute of Medicine writes, “States with broader nursing scopes of practice have experienced no deterioration of patient care.”

    This is a protection racket. Any state legislature that extends it is choosing higher health-care prices — and health-care costs — for no good reason."​





    "http://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/15/wonkbook-doctors-for-higher-health-care-costs/
  2. LittleBlueLW
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    LittleBlueLW Premium Member

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    Why not get rid of all licensing requirements in any profession?

    Public safety and protection be damned!

    With regards to the nurses, I use one almost exclusively for the routine head, chest, sinus issues. Easy to see for sure but I have no idea what they bill my ins. Co.
  3. DaveFla
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    Calling all lawyers -- Calling all lawyers...
  4. MichiGator2002
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    MichiGator2002 VIP Member

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    "Unleash" here basically meaning "hype up the fact that the gross overload of our healthcare system en route will require them to do jobs previously reserved for people with higher educations and licensing criteria than their own have as being a good thing".

    I've said this many time -- liberal healthcare and social policy in general will yield PAs and RNs doing what MDs used to do (PAs maybe even being de facto specialists), LPNs doing what PAs and RNs used to do, and LPNs probably just being a $8/hr unskilled job.

    I'm sure all that "unleashing" without anybody ever having taken the same schooling and board exams that required for the person they are replacing will in no way lead to missed diagnoses and other problems.
  5. wgbgator
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    wgbgator Sub-optimal Poster Premium Member

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    I think you are mistaking "liberal healthcare" with what Taylorist-style capitalism does to any craft profession where demand explodes: Segment it, deskill it, lower labor costs, increase productivity. That is, unless your argument is that "conservative healthcare" is protecting doctors from the forces of the market.
  6. QGator2414
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    I have no issue with allowing NP's and PA's to own/operate their own practices without a MD over them. My only concern is that I do think it could expedite the shift to corporate medicine as I can see the corporate chains dumping many of their MD's but people should get what they pay for.
  7. MichiGator2002
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    MichiGator2002 VIP Member

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    Except capitalism isn't what's doing it here and now, is it? Anticapitalism is. Anti-actuarialism in an actuarial industry is. Yeah, you can see those things happen in a profit seeking endeavour, but the check on it is if you lower quality to increase productivity, the profit motive itself is the check on that; you can only do it as far as allows you to still make money. Whereas ObamaCare tacitly mandates that insurance companies and healthcare providers can't worry about something as banal as solvency to check this behavior; they've got to keep the turnstyles moving. And if you hand it to the government, which doesn't ever have to run at anything other than a loss, forget about it -- "RN" will be more like "first job after high school" than anything else.
  8. g8trdoc
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    g8trdoc Premium Member

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    So unqualified people doing work that is way out of their scope. These types of people have their place but diagnosis is out of the question. The best way to put it is it's like putting on a blindfold and treating horses. It will work out great till someone throws zebra in there and the practitioner doesn't know the difference. It's not the fault of the PA or Nurse Practitioner that they don't have the knowledge to tell the difference they simply don't have the education. Personally I took 18 months of general pathology the another 16 months of oral pathology. Nurse practitioners are luck to get 3 months. If they want to be a Doctor then they need to go to medical school.
  9. wgbgator
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    wgbgator Sub-optimal Poster Premium Member

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    Well, I don't know what "anticapitalism" is, but we have a market-driven healthcare system, that operates for profit. So, I'm going to say that yes, it is Taylorist-style capitalism. The fact that insurance and medicine is (and has been for many decades) heavily regulated doesnt change the fact that its done so in a capitalist context.
  10. Row6
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    Row6 New Member

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    Several posters ignoring the fact that states that already allow expanded duties for np's and pa's show no downturn in health stats. Ignored by others is the artificially limited number of med school slots. Much of medicine is rote and/or treated by too busy docs who give rote treatment. The definition of a good professional includes a willingness to acknowledge when they are over their head and need more expert counsel. There is no reason to think np's and pa's are less professional than docs in this regard.
  11. Row6
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    Row6 New Member

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    Your solution is based on limiting access to health care for millions.
  12. LittleBlueLW
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    Do you mean 'for millions'?
  13. mocgator
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    mocgator Well-Known Member

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    Health care quality about to plummet. Who predicted that??
  14. oldgator
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    I've been an RN for many years now. For the most part nurse practitioners and physician assts are quite competent in their role as it has been for many years now.

    My chief concern regarding nurse practitioners becoming more independent is in regard to their making differential diagnoses in situations in which a patient has more than one diagnosis occurring. With each additional condition, etc a patient has going the the complexity of diagnosis increases exponentially. Doctors have dealing with that as a great part of their training. The training of nurse practitioners does not have that as a part of their training as the doctors do. With nurse practitioners operating under the cap of a MD the MD has the responsibility and ability to spot other things going on the nurse practitioner likely doesn't have the scope of education to identify. The problem then becomes the nurse being in over their head without realizing it.

    Finally, if nurse practitioners do become independent of MD's and take on more responsibilities, etc---you can bet their prices for services will increase and get closer and closer to that of MD's.
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  15. Row6
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    Row6 New Member

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    I did and thanks for the correction.
  16. Row6
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    Row6 New Member

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    Valid points though on the latter, everyone in medicine is going to see their compensation decrease. We can't afford the current system. On the former, stats in states that have tried this do not show any increase in related problems according to studies.
  17. Wormwood56
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    Exactly. I've worked in the healthcare profession for decades. NPs and PAs have nowhere NEAR the knowledge and skill base as physicians. Not even close. There is a REASON why they have to work under the supervision of a physician, and it has little to do with money. The reason they exist at ALL is in order to have more practitioners distributed throughout large areas of the country where MDs are few and far between. They were created to augment a physician's practice, not to replace it.

    Well on our way down the road to Soviet/Cuban-style healthcare...
  18. oldgator
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    It's still early days yet in this transition and the issue I mentioned is one that would take extensive study over time. In addition, the issue of missed diagnosis because of being obscured by other illnesses/conditions would be more likely in some demographics than others(elderly people, trauma, homeless, etc).
  19. Row6
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    Row6 New Member

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    OK, as I said, valid point though one I think a work around could be designed or one - like too busy docs - we have to live (no pun intended) with.
  20. sappanama
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    most assuredly not for providers, 40 years ago it may have been close, but it hasn't been in a long time. all but very few have reimbursements dictated, some are kept off panels, the guy who wrote the book on peri - acetbular osteotomy can opt out of the system, but ones like him are very rare, james andrew is an example of a guy who may get paid what he asks, but not the 5000 other surgeons doing acl's. i am not intuned with the exact perameters of capitalistic context, but it is not what say a home builder (was given bid of 296/ft for a house we want to build), or lawyer(450/hr for a planning , financial trust etc, 300/hr for wills) (other than a lawyer taking a case as a public defender), or plumber (paid 85/hr for a midnite pipe rupture plus parts), or auto mechanic (recently paid 115/hr at the chevy place) thinks of as capitalistic. It has been a good career, but not like you seem to think, in many ways the young ones i think will have a much better go, guaranteed check, no or very little call, much improved "life" outside of medicine, but I don't think any reasonable person seriously thinks a 2 year clinical program is equal to 8-10 years of clinical instruction, that would be like saying a guy with no college could build a house better than a UF grad with a degree in building construction, oh wait.

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