Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!

“Like doctors, more nurse practitioners are heading into specialty care”, a recent article in the Washington Post (June 17, 2024) by Michelle Andrews, a contributing writer for KFF News, and McKenzie Beard, makes the point that

Nurse practitioners have long been a reliable backstop for the primary-care-physician shortfall, which is estimated at nearly 21,000 doctors this year and projected to get worse. But easy access to NPs could be tested in coming years. Even though nearly 90 percent of nurse practitioners are certified to work in primary care, only about a third choose the field, according to a recent study.

That study, called ‘No One Can See You Now: Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change)’ was published by the Millbank Memorial Fund, and goes on at length to explain those reasons, and what needs to change.

Spoiler Alert: Like physicians, primary care nurse practitioners make less money, often for more work, and far less restricted scope of practice. Or, borrowing from an old political mantra, “It’s the money, stupid!” Or, as the WaPo article quotes Candice Chen, an associate professor of health policy and management at George Washington University, “We get what we pay for.”

It is, of course, more than just the raw amount of money. It is also how much NPs – and physicians – are paid for the amount of work that they do. This work is undervalued for primary care, based upon the notion that, somehow, being expert in a narrow specialty and knowing a lot about a little, is worth more than having a broad knowledge and being able to help a lot of people, most people, a great deal. Thus, subspecialists dramatically limit their practices to what they feel most expert at and expect the primary care clinician to do everything else. This often includes preparing people for a procedure and following them up after, which are both completely the responsibility of the person doing the procedure. Subspecialists particularly like to send paperwork back to primary care. “Your primary care doctor (or NP) will have to take care of this.” Implication: ‘Unlike primary care clinicians, I do important things.’

I would argue that managing people’s health is doing important things. Which is what the primary care clinician (family physician, general internist, general pediatrician, or the NPs that work in these fields) does. Managing the actual person, you, not just one of your diseases, or one aspect of one of your diseases; being knowledgeable about you, your life, and the interactions of all your conditions and the impact that they have on the rest of your life.

How might this manifest? Let’s say you have knee pain. You go to your family physician, who examines it, and decides that you need an x-ray. They review the x-ray and the report, and decide that you might benefit from seeing an orthopedist. They fill out the referral. Then, after the consultation and recommendation from the orthopedist, they review it, and decide how to implement the treatment. That is a lot of work. The orthopedist was done in a few minutes. Guess who gets paid, altogether, more?

Like the physicians that employ them, NPs are often very expert in their limited area (say, heart failure management), but often do not know how to manage that problem in the context of a person whose other diseases or medications may complicate that. This is where the (underpaid) primary care clinician, physician or NP, has to come in. It is a lot of responsibility, a lot of work, and often a lot of extra hours. One NP profiled in the WaPo article is taking training to become a dermatological NP. This is one of the medical fields with the highest pay/work ratios. Most of its work is not emergent and can conveniently be scheduled during the day during the week, and is less likely than many other specialties’ work to interfere with treatment for other conditions. And it is very highly reimbursed.

Should people be paid based upon the amount and difficulty of their work? If we did, people doing the most difficult work that everyone agrees needs to be done but that most people do not want to do (e.g., picking up the garbage, doing farm work in the hot sun) would be paid more than those who get fancy offices and lots of perks and boss folks around (e.g., CEOs). But difficult can have other definitions; this is really a separate discussion. In health care, for physicians (and now NPs) it should be how they contribute to the system. Currently the usual measure is money, that is, how much a given practitioner brings into the practice, or more commonly now, to their employer (often a health system), which is based on how much payors (insurers) pay for different things. That amount is not God-given, but a matter of policies that could be changed. Two mechanisms through which the amount of reimbursement is set are the RUC and the facility fee. The RUC is a group of non-governmental physicians appointed by the AMA that makes recommendations on how Medicare money should be divided up between specialists – like “one gallbladder removal is worth 6 complete examinations”, or whatever. Medicare is not required to accept their recommendations, but they usually do. And – surprise – the RUC is mostly made up of subspecialists, not primary care clinicians!

The facility fee is an amount that Medicare (and other insurers, see below) tack on to the physician fee if the practice is owned by a health system rather than a physician, and is often several times the fee for the procedure. To be clear, this means that if I receive a procedure today from a physician in their office and you get the same procedure in the same office by the same physician next week, but in the interim that practice has been acquired by a health system, the charge will be MUCH more. Medicare or your insurance may pay it, or most of it, but your co-pay will be much higher, and all of our premiums go up. This practice is hardly ever made apparent or explained in advance to patients (“Hi, thanks for calling. Just to let you know, Dr. Smith’s practice was just acquired by the MuchProfit Health System, so you will be charged three times as much for your procedure as you would have been last week.”) This is so insidious (not to say evil, but it is evil) that even doctors are often surprised, as revealed in the essay by Dr. Danielle Ofri in the New York Times (June 17, 2024) ‘Even Doctors Like Me Are Falling Into This Medical Bill Trap’ and the follow-up letters and comments from other physicians.

The fact that facility fees and the RUC are about Medicare does not mean that they do not affect the fees, cost, and reimbursement from other insurers. Almost all insurers payment rates are set as multiples of Medicare. That is, if Medicare pays $100 for something, they may pay $150 or $200 (and, more recently, those multiples are lower, with patient responsibility higher). Changing these two factors, facility fees and RUC allocations, for Medicare will affect all insurers and make a real difference in income (which is why most subspecialists and hospitals oppose them).

Should primary care clinicians be paid more, or subspecialists less, or somewhere in between? Whichever, by decreasing the difference more clinicians are likely to enter primary care specialties. And, whichever, the raking off of facility fees to increase the wealth of hospitals, not to mention the pocketing of huge profits by insurers, has to stop.

Medicare for All, or "Eat well, take your medications, and good luck!"

I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:

Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 

And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can not do a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!