The following is a gues post by Seiji Yamada, MD, MPH
In July 2015, on the
50th anniversary of the founding of the University of Hawaiʻi John A. Burns
School of Medicine, the school invited its alumni for a Saturday morning
symposium on "Transformative Medical Education in Hawai`i." The last panel of the morning, on the future
of medical education in Hawaiʻi, featured the deans of medicine, nursing,
social work, and the associate director of public health.
Dr. Peter Donnelly -
Kanaka Maoli family physician, practicing on the Neighbor Islands, my mentor in
Hawaiian Pidgin and how to be local (I fail abjectly on both counts) - asked
what the panelists think of nurse practitioners telling him that
they can do anything he can do, at less cost. One panelist suggested,
"If you can't beat them, join them," so you might as well go get your
MBA.
The claim that a
non-physician provider can do the work of a physician at less cost ignores (perhaps
willingly) the distinction between earning less and costing less. Certainly non-physician providers earn less
than physicians. Dr. Stephen Kemble - psychiatrist
and a stalwart for single-payer, who had been decrying the business takeover of
health care from the audience all morning - noted that with regards to the
provision of mental health, the evidence shows that non-physician therapists
can actually cost the mental health system more than
psychiatrists. (He was citing an
unpublished study performed by a Hawaiʻi health insurance outfit.)
Of note, a study in the September 2015 issue of Medical Care found that diabetic patients cared for by nurse practitioners had comparable rates of preventable admissions as primary care physicians. The provider who cares enough to invest the time to talk with and assess the patient may also decide upon less intensive courses of care. The medical profession as a whole must shoulder part of the
blame for the present situation. Specialty
control over the reimbursement system results, naturally, in disproportionately
higher reimbursement for procedures and disproportionately lower reimbursement
for primary care. See Outing the RUC: Medicare reimbursement and Primary
Care. [1] This ensures that most medical students will choose
specialty training so that there are not enough primary care physicians to care
for all of us. To the extent that
physicians obtain MBAs and figure out how to game the extant reimbursement
system [e.g. hire an N.P. to consult on patients so the gastroenterologist can
perform colonoscopies in the surgicenter (anus to anus time of under 10
minutes) all day] - the proceduralist specialties are complicit. Indeed, there is no reason why the
gastroenterologist should explain the risks, benefits, and the bowel prep for
screening colonoscopies.
We family physicians learn
during residency that the
practice of primary care is, in many ways more complex than specialty practice. [2] A well-trained, experienced
provider of any discipline can deal with many complex patient problems for
which a less intensively-trained, less experienced provider may order
unnecessary tests or referrals. Thus, while a primary care physician
may earn more than a non-physician provider, the cost to
the health care system may be less.
In addition, the
provider who cares enough to invest the time to talk with and assess the
patient may also decide upon less intensive courses of care. These days, you can be largely assured that
if you presents to the ED with a headache, you’re going to get a CT scan of
your head. If you present with abdominal
pain, you’re going to get a CT of your abdomen.
Many patients with symptoms clearly suggested of reflux are kept in the
hospital for observation to “rule out myocardial infarction.” So,
conversely, while a primary care physician may earn less than an
emergency physician, the cost to the health care system may also be
less.
While part of the
problem may be that the nursing profession is eager to escape the yoke
long placed upon it by the medical profession - perhaps the larger problem is
what Dr. Kemble identified as the incursion of the business model into health
care.
The business model is
predicated on delivering a standardized product with quality controls on what
can be measured at prices that the market will bear. Thus at any fast
food franchise, one can reasonably expect a hamburger without too much E.
coli in it, at the price listed behind the counter. The MBAs who
run our health care systems have no concept of the importance of, for example,
a longitudinal patient-doctor relationship to health outcomes. If they
can replace an experienced primary care physician with a lower-paid
"provider," it's better for the bottom line.
We in family medicine
should not be picking a fight with the nursing profession. (For
the sake of patient outcomes, I am happy to help nurse practitioners improve their practice, and I am happy
to learn from them what they do best.) I think that the main problem is
the marketplace model of health care. Capitalism has always depended on
maintaining a certain percentage of unemployment in order to keep workers a
little afraid of losing their jobs and therefore toeing the line. The
corporate takeover of health care means pitting the lowest rung of the
physician class, the primary care physicians, against a growing workforce of
providers with different qualifications eager to take their jobs. From
where I stand, I think that all health workers need to unite against that.