Posted on 01/14/2020 5:59:33 AM PST by Kaslin
President Trump recently issued an Executive Order protecting and improving Medicare for our nation’s seniors. The October 3, 2019 order was intended to increase Medicare beneficiaries’ access to primary care. The executive order is little more than a policy goal at this point. Item five of the executive order annoyed physicians. It gave the Secretary of Health and Human Services (HHS) 12 months to formulate a proposal to expand the autonomy of nurse practitioners (NPs) and physician assistants (PAs) working in the Medicare program. Under the proposal, so-called midlevel providers would be allowed to practice with far less supervision, prescribe medications and bill Medicare when they see Medicare patients. The proposal also seeks to equalize compensation paid to physicians and PAs/NPs treating Medicare patients.
NPs and PAs have been fighting for greater autonomy for decades. However, the proposal has some powerful enemies: doctors. This is how it currently works: in virtually all states doctors are responsible for the care provided by NP/PAs. Some states require NPs/PAs to have collaboration agreements with physicians. Yet, not all physicians want to collaborate with NPs/PAs and those who do naturally demand a portion of the revenue and often place restrictions on what tasks NPs/PAs can perform. Many other states require a form of direct supervision, often requiring a percentage of patient case files be reviewed by the supervising physician. Thirty-nine states even place limits on the number of NP/PAs any one doctor can supervise.
This turf war, known as scope of practice, is raging not just on Capitol Hill but also in state legislatures all across the country. It is easy to see why physicians oppose greater autonomy for midlevel providers. Recall I said that doctors currently must supervise midlevel providers in virtually all states. Thus, most NPs and PAs either work for doctors or work with doctors and give them a cut of their pay. Under President Trump’s initiative, physicians would lose some of their ability to profit off NPs/PAs' work. More galling is the fact that physicians have much more rigorous training requirements, higher student loan balances yet may be paid the same for a 20-minute office visit with a senior. With this executive order President Trump seeks to turn NPs/PAs into primary care physicians’ competitors rather than employees and collaborators.
Why allow seniors to make appointments with nurse practitioners and physician assistants independent of doctors? Because the vast majority of medical conditions that patients experience are simple problems that don’t require a doctor to diagnose or treat. More complicated conditions are easily referred to specialists. General practitioners participating in Medicare already do this. Furthermore, numerous surveys have found NPs have high satisfaction ratings and are rated as better listeners than physicians. Indeed, various surveys have found physicians tend to interrupt their patients with seconds after patients begin describing symptoms. More to the point, 78 million Baby Boomers will become eligible for Medicare by 2030 and many will be unable to find a primary care provider unless the supply is expanded. The Association of American Medical Colleges predicts a shortage of nearly 122,000 physicians by 2032.
Non-seniors should care about turf battles in Medicare because what Medicare does affects other areas of medicine. Current regulations that govern the practice of medicine are exclusive. Stated another way, state and federal regulations purposely create barriers to entry, making it more difficult to practice medicine and inhibits competition. In his book Capitalism and Freedom, Nobel laureate Milton Friedman described the American Medical Association as the “strongest trade union in the United States.” Trade unions reduce competition, not promote it. Cartels and professional guilds are never pro consumer. They exist primarily to boost the wages of guild members.
Whether in rural areas or urban areas, Medicare or private health plans, patients should have the choice and convenience to decide who they want to see. Patients should be free to see a nurse practitioner, a physician assistant, a primary care doctor or a physician specialist depending on their needs. When doctors argue all other medical staff should report to physicians in the name of patient safety, keep in mind the safety they are most concerned about is the safety of their income stream.
and when you are in the ER with chest pain? Do you want the lecture or treatment
Somehow NPs and MAs are unable to do this - or so say doctors, ex-doctors, and family members on this thread.
Right before I retired as a nurse, our yearly mandatory education had a topic on how to communicate to obese patients about their weight. We were told not to say the word “obese” because the word may offend them.
Patient satisfaction scores determine employment and salary now. Administrators who now control healthcare ( thanks to the ACA) control physicians, and many physicians shy away from the discussion anymore.
It happened to me. A morbidly obese patient wanted me to ask the physician for a prescription for a wheelchair she could use at work to maneuver around the office. She was 25 years old. I told her that it was good for her health to mobilize. I spoke to her in a very nice manner. However, she wrote a complaint against me to administration.
Why should a healthcare professional even bother anymore, when having frank discussions may result in a complaint and possible termination.
People know what they need to do, and having Medicare pay for it is a waste of money.
Because midlevels are not trained enough to know that something that appears to be mild may be something more serious. However, if they get autonomy from supervision, then they better have some good malpractice insurance and not rely on a supervising physician to train them.
I knew a new NP grad who was hoping at her new job that the MD would train her in that specialty. That is crazy. If you graduate from a program, you should be able to effectively treat patients without relying on physicians to train you.
I know that, and I have no medical training.
I agree with you.
Having been married to a doctor since med school in the 60s and members of my family and myself working in the field, the golden age of medicine is almost dead.
Foreign trained doctors who tend toward cultural illeteracy. Med schools which turn out grads who are not taught the basics of what used to be the all important physical exam which included touch, hearing, and looking all group to set us on the path to very poor medicalcare.
PAs and NPs are plain dangerous when turned loose as primary providers. Med school grads who go directly to a specialty residency, bypassing a general internship, end up with tunnel vision always seeing their specialty nail in their patients.
The best suggestion I have heard is to require every graduate doc to spend two years being mentored by the dinosaurs whose experience is invaluable. Mayo’s is doing something like that now.
The White House proposal guarantees sub par medical care. Resist!
One of the
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