Is there a creeping deregulation of health care?

by on May 26, 2015 at 9:15 am in Economics, Law, Medicine | Permalink

Nebraska became the 20th state to adopt a law that makes it possible for nurses in a variety of medical fields with most advanced degrees to practice without a doctor’s oversight. Maryland’s governor signed a similar bill into law this month, and eight more states are considering such legislation, according to the American Association of Nurse Practitioners. Now nurses in Nebraska with a master’s degree or better, known as nurse practitioners, no longer have to get a signed agreement from a doctor to be able to do what their state license allows — order and interpret diagnostic tests, prescribe medications and administer treatments.

This is especially important for rural communities.  The economist speaks:

“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”

The full article, by Sabrina Tavernise, is here.

1 Al May 26, 2015 at 9:37 am

It’ll never happen in California. We’re too progressive.

2 Jan May 26, 2015 at 9:57 am

Interestingly, scope of practice laws in health care don’t track the Red/Blue divide. If anything, the more conservative “less regulation” states are the ones preventing nurses from practicing up to their training. http://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment

It is good that this is happening. Doctors a lot and they should hand over the keys for types of care that don’t require their direct involvement.

3 Al May 26, 2015 at 10:47 am

It’ll never happen in California. We’re too conservative.

4 Dom May 26, 2015 at 11:04 am

“Doctors… should hand over the keys..”

.

The American Medical Association (AMA) was founded in 1847 with the practical goal of establishing a government backed medical monopoly to radically increase physician incomes.
AMA efforts were spectacularly successful, eventually becoming the most powerful labor union in America.

AMA’s quest was originally driven by increasing economic competition from nurses, pharmacists, midwives, etc.

AMA strategy was to impose strict government licensing on medical practice and to sharply reduce the graduate output of medical schools.

AMA created its ‘Council on Medical Education’ in 1904 to shutdown over half of all medical schools then in existence, via establishment & control of State Medical Boards. Severe admission limits to remaining schools were set to further reduce the number of doctors graduated into the marketplace.

AMA ultimately built a truly impressive government-guild system that (until very recent years) has almost completely insulated physicians from cyclical and structural unemployment/underemployment.

Restricting labor supply has really worked well for U.S. medical doctors over the past century, but at a high price to the public in blood and treasure.

5 Jan May 26, 2015 at 1:21 pm

Yup. Doctors aren’t the only problem in US health care, but they share a lot of the blame.

6 Thomas May 26, 2015 at 3:57 pm

I don’t understand? They’ve been essentially a highly successful union. Shouldn’t the AMA be a model to emulate for the rest of us workers?

7 Jan May 26, 2015 at 4:22 pm

Heh. In the UK doctors truly are a union–yet somehow they haven’t driven their health care system into the ground.

http://www.dailymail.co.uk/news/article-2162861/Doctors-strike-90-GPs-snub-union-working.html

8 mulp May 26, 2015 at 6:16 pm

“Restricting labor supply has really worked well for U.S. medical doctors over the past century, but at a high price to the public in blood and treasure.”

Which of the following are true:

A) conservative Republicans have been demanding higher Federal spending on residencies to increase residency slots to boost the supply of doctors

B) conservative rich elites are funding tens of thousands of residency slots at private for profit hospitals to boost the supply of doctors dramatically

C) conservative Republicans are passing huge increases in funding for NIH, DARPA, et al to boost the number of phds in health care to deliver new technology to boost productivity of doctors: AI, better testing, better treatments, better tracking of patients and treatment to advise doctors with data mining

D) conservative rich elites are investing billions in R&D that will be cheaper than depending on doctors experience and skill

In my lifetime, the AMA and conservatives have been linked arm and arm, with doctors dealing in the real world with patients breaking with the AMA.

I doubt you can find more than 3 out of 10 doctors who oppose doubling the Federal funding on residencies, or oppose the Federal budgets on R&D, both of which would increase the supply of medical “doctors” who earn the highest incomes.

9 Jan May 26, 2015 at 1:18 pm

Oops, that should read “doctors _cost_ a lot.”

10 JWatts May 26, 2015 at 1:49 pm

“If anything, the more conservative “less regulation” states are the ones preventing nurses from practicing up to their training.”

Your link doesn’t really support that assertion.

11 Jan May 26, 2015 at 4:12 pm

Sure it does. The entire South is comprised of “Restricted Practice” and “Reduced Practice” states that regulate nurse practitioners out of providing services in line with their training. The majority of the Northeastern states and all of the liberal Northwest don’t restrict nurse practitioners.

12 Al May 26, 2015 at 5:19 pm

So, er, what would be the Progressive/Democrat theoretical basis for this deregulation?

What part of the pro-regulation, progressive, Democratic political philosophy supports loosening restrictions/regulations in this case?

And whatever part that is, how can it justify increasing risks which are virtually guaranteed as a result of allowing less educated, less stringently licensed practitioners to treat and medicate the general population?

13 JWatts May 26, 2015 at 8:30 pm

“Sure it does.”

No, any intelligent person looking at the map would realize the data is mixed. You’re cherry picking to create a narrative. The two biggest blue states in the country are California and New York and one is restricted and the other reduced.

14 Jan May 27, 2015 at 8:05 am

You’re an idiot.

15 Jan May 27, 2015 at 8:07 am

There are a handful of outliers out of 50 states. Good job there. Really, no trend whatsoever.

16 Todd May 26, 2015 at 10:09 am

SB 323 passed the CA senate 25 to 9 May 7, 2015.

17 Al May 26, 2015 at 10:38 am

Yes. SB 323 must now be approved by the CA Assembly. We’ll see if the provision allowing nurse practitioners to operate without oversight by an MD is retained.

18 Al May 26, 2015 at 10:42 am

This same thing was tried in CA in 2013 but failed:

“This is the second time around for Hernandez’ bill. A similar measure he introduced in 2013 failed amid opposition – first from the California Medical Association, which represents physicians – and then from the American Association of Nurse Practitioners, which dropped its support for the bill after it was amended to appease the physicians’ group.”

http://www.scpr.org/news/2015/02/27/50085/bill-would-expand-authority-of-nurse-practitioners/

19 Sam L. May 29, 2015 at 12:54 pm

Misogynists! Women h8rs! #War on Women

20 Shangwen May 26, 2015 at 9:39 am

The territorial creep of nurse practitioners is largely happening at the expense of family doctors. More likely this is not deregulation but an evolving grand bargain between medicine and nursing, in which the physicians gradually shed their lowest-remunerated specialty and cede that scope of practice to nurses. Nursing thus gains a highly-paid specialty with higher status. My speculation is that Family Medicine as a specialty will effectively disappear. When physicians are composed solely of specialists, and nurses acquire more lucrative niches, I would expect wage growth for both groups to accelerate even faster.

21 Urstoff May 26, 2015 at 9:52 am

The proliferation of PAs and NPs doesn’t seem to be lowering healthcare quality. But the important question is whether it is lowering healthcare costs.

22 collin May 26, 2015 at 10:01 am

In how many cases do family doctors actually know their patients and family members. In most cases, I expect very little and so a little patient self-selection on medical needs can probably save a lot of money here.

23 dearieme May 26, 2015 at 11:06 am

“In how many cases do family doctors actually know their patients and family members?” The main obstacle at our practice is that the GPs keep pissing off for lengthy maternity leaves.

24 Jan May 26, 2015 at 1:25 pm

An alternative approach to maintain a steady working population is immigration. How do you feel about more immigration?

25 TMC May 26, 2015 at 1:57 pm

They’ve been trying that in the UK. Not working out too well.

26 Sam Haysom May 26, 2015 at 1:59 pm

Another alternative would be to encourage women to avoid becoming doctors or to avoid pursuing careers that require lots of specialized schooling. How do you feel about that option? See two can play this game.

27 Jan May 26, 2015 at 2:23 pm

Encourage away. See how well half the electorate likes that. Women will continue to do what they want. 😉

28 A Definite Beta Guy May 26, 2015 at 4:24 pm

Waste scarce resources?

29 anon May 26, 2015 at 1:03 pm

This article from the economist talks about your point.

http://www.economist.com/node/21556227

I agree generally, but I think there will be a niche market for Family Practice docs who serve high income patients.

30 Pshrnk May 26, 2015 at 11:39 am

It is increasing health care costs and decreasing quality. It will take decades for the cancers from the extra unnecessary xrays etc they order to show up in increased cancer rates. NPS order more tests, make more referrals and do less treating themselves. Many hospitals and group practices like them from a financial standpoint, because they do work for a lower salary while increasing overall expenditures.

31 Urstoff May 26, 2015 at 11:45 am

Interesting. I was just basing it off of subjective perception. Do we have stats on the quality of care provided by NPs and PAs?

32 Pshrnk May 26, 2015 at 12:17 pm

Not practicing independently of MD oversight. Cost is difficult to study…..however in my career I have been part of two large networks that worked under capitation and found NPs more costly than MDs because of greater utilization of unnecessary tests and referrals.

Now there are many unanswered questions since it is very difficult to design ways to pay health care providers without the risk of incentivizing to do too much or too little.

In the group where MDs could increase their personal income somewhat by spending less on tests and referrals did the MDs test and refer too little? Our review of this showed no evidence of such. But of course that was MDs reviewing other MDs decisions….Hmmmm.

Might NPs whose charts are reviewed by their MD collaborator order more tests and referrals than NPs practicing independently? Would they test more as CYA with their MD? I doubt it, since they could ask their collaborating MD whether she wanted a particular test ordered. Would they order even more tests if practicing independently? Ordering a test is sometimes a security blanket. More experienced MDs on average order fewer tests than do the less experienced. How does NPs test and referral ordering compare with MDs with the same number of years experience? Is their a confound in the average NP having fewer years experience than the average MD?

33 Jan May 26, 2015 at 1:26 pm

Do you have any evidence of this?

34 Jan May 26, 2015 at 1:24 pm

I don’t think so. Primary care is perpetually in short supply. Docs that want to be in that business can be. We could certainly pay primary care docs more than we do–and we should. But GPs are mainly fighting with the specialists for the money–not NPs and PAs. You should investigate the AMA’s Relative Value Scale Update Committee.

35 anon May 26, 2015 at 1:34 pm

Specialists go to school longer, though.

I’m about to finish medical school and am shooting to become a cardiologist. This requires 4 years medical school + 3 years internal medicine residency + 3 year cardiology fellowship AT THE VERY LEAST. If I want to do interventional cardiology, I do another fellowship for an additional year or two. I make about 50k during residency and fellowship.

Family practice docs do a 3 year residency only.

36 anon May 26, 2015 at 1:36 pm

I should also add that specialist training is in many cases more intense, with higher on call hours, more hours, more complicated patients, more life-and-death scenarios…generally more demanding.

37 Jan May 26, 2015 at 2:57 pm

Fair enough. Going to school longer should translate as a pay bump, but the premium is very high. Do you think a cardiologist should make more than twice as much as a GP or pediatrician? Or, perhaps more importantly, should the US have a higher specialist-to-generalist ratio (~70% are specialists) than any comparable country?

38 Mondfledermaus May 27, 2015 at 9:53 am

Yeah but those extra three years earn you the equivalent of a Letter of Marque, you will be making 500K+ a year and still be able to tee off at Country Club by 4:00 PM, on weekdays.

And regarding Nurse Practitioners, here in Georgia my experience has been that they have been added to some practices, but I still get billed as it was a Physician, so no benefit at all for consumers, just adding more money to the already well lined pockets of the doctors.

39 Shangwen May 26, 2015 at 1:37 pm

I agree it’s in short supply, but no more so than many other specialties, which also have greater political power. GPs are fighting with specialists because they take from a med remun pool, but the larger policy question is whom to pay for primary care. Surprisingly, many politicians have been encouraging more NPs, and AMA criticism has been mostly tepid performance art.

As an additional exit strategy, many younger GPs can (and do) decide to go back and do a specialist residency.

40 Alan May 27, 2015 at 6:45 am

We could certainly pay primary care docs more than we do –
written like someone not paying the bill.

41 8 May 26, 2015 at 9:51 am

The biggest cost driver was employer paid health insurance. The ACA broke that link to push in a more regulated direction, but by breaking the link between employment and health insurance, it has done the heavy political lifting for deregulating the market. With less people receiving benefits from work, there will be less opposition to taxing health benefits as wages and deregulation that allows insurance companies to offer cheaper plans will be popular. Here, the individual mandate is also a stealth tool for deregulation. It forces people to buy plans, and once the cheap options return under a Republican president (which could be done via executive order thanks to precedent) many people will sign up for those cheap plans and begin paying for typical healthcare costs and tests out of pocket, leading to a real market for these services.

42 Urstoff May 26, 2015 at 9:53 am

So the ACA laid the foundations for a voucher system for healthcare? If so, then it might not be such a bad piece of legislation.

43 Jan May 26, 2015 at 9:57 am

You started off good…

44 Jon May 26, 2015 at 10:38 am

The ACA has many elements conservatives should love. Eventually, unless there is a dramatic slowdown in cost growth, most employer plans are likely to become taxed under the “Cadillac plan” tax provision. The basic bronze plans have what would qualify as large deductables and copays (thousands of dollars), except for preventive care. The only thing for them to hate are the minimum standards, guaranteed coverage, and individual mandate.

The republican answer–no guaranteed coverage or individual mandate, but government sponsored risk pools, just makes us pay for high risk people through taxes instead of insurance premiums or penalties. The big difference is that the ACA mechanism makes it harder for the government to skimp on the coverage of the high risk people (as they can with Medicaid through the low reimbursement rates in some states).

45 Harun May 26, 2015 at 12:36 pm

“The republican answer–no guaranteed coverage or individual mandate, but government sponsored risk pools, just makes us pay for high risk people through taxes instead of insurance premiums or penalties.”

1) High risk pools charge more to those specific customers. Therefore they are “just making us pay more via taxes.” In fact, it shifts the burden back on the individual, be they someone born with an unusual problem or a free-rider who waited until they needed insurance to buy it. This allows the rest of us to have “normal insurance” There may be room for some direct subsidy, such as we do with dialysis.

2) The Republican answer also includes a national market to increase competition, and using tax credits – a much simpler system than government exchanges, which cost literally billions to set up, and now are running in the red. I’m amused that so many on the left railed against big pharma wasting money on advertising, but they had no problem with billions spent on duplication of exchanges, wasted advertising on non-working state exchanges, etc.

3) Guaranteed coverage is the holy grail…we’d all like that, but we have seen insurance markets collapse when its been implemented. This is like saying the GOP is against free ponies…when in fact, if they were indeed free gifts from God, no one would be against, them, but they ain’t free!

4) Individual mandate: some GOP plans include this. Some are against this for philosophical reasons.

46 Jan May 26, 2015 at 2:21 pm

1) There is no such thing as “normal insurance” for healthcare. People’s care needs fall along a wide spectrum. with no clear “high risk” boundary.
2) National market to increase competition” –selling insurance across state lines has been tried repeatedly and has had almost no impact whatsoever
3) Not having guaranteed coverage was one of the weakest parts of the system. Not only is it unfair to people who are unlucky enough to have pre-existing conditions, it defeats the purposes of insurance. This goes back to the fact that health care and illness doesn’t operate like any other kind of market, and yes it also incorporates some elements of social insurance and societal responsibility. Guaranteed coverage–now that it is out there–is something that even the Republicans wouldn’t repeal.
4) Any reform that includes guaranteed issue (as any viable ACA replacement would certainly contain) will also have to include an individual mandate, Proposals that don’t are not viable.

47 Thomas May 26, 2015 at 4:03 pm

1. The spectrum argument as you use it is tired. There is very little difference between 1 and 2, 2 and 3, 3 and 4, … 1 and infinity. 2. Source please: the claim that additional competition has “almost no impact whatsoever” is counter-intuitive.

48 Jan May 26, 2015 at 4:29 pm

1 and 3 are similar, and true. Those sentiments align with what most people believe about the role of health insurance and its role as a form of social insurance.

2 may be counter-intuitive, but it is true. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2012/rwjf401409

4 What can I say? I am certain that guaranteed issue is not going anywhere.

49 JonFraz May 28, 2015 at 3:24 pm

Actually insurance can be sold across state lines– it just has to conform to the regulations of the state where it is sold.

50 JonFraz May 28, 2015 at 3:22 pm

Re: High risk pools charge more to those specific customers. Therefore they are “just making us pay more via taxes.” In fact, it shifts the burden back on the individual, be they someone born with an unusual problem or a free-rider who waited until they needed insurance to buy it. This allows the rest of us to have “normal insurance” There may be room for some direct subsidy, such as we do with dialysis.

Overall a single pool for everyone forces insurance companies to hold the line on premiums: if they charge too much they lose business (this is basic econ 101 stuff). This system (ideally) produces the lowest possible premium, just as having one price per customer does the same for everything else from gasoline to computers to Big Macs. Assuming one is not a greedy jerk who wants special privileges, what’s not to like?

Re: Guaranteed coverage is the holy grail…we’d all like that, but we have seen insurance markets collapse when its been implemented. –

????
In what alternate universe? Sure hasn’t happened in this one! Massachusetts has had it for over a decade– and its still has a functioning insurance market. A number of foreign companies have had that for decades– and have LOWER healthcare costs. (Why do I get the feeling you work for the insurance industry and are getting paid to spread disinformation?)

51 Bob from Ohio May 26, 2015 at 12:50 pm

“The ACA has many elements conservatives should love.”

Your side keeps saying that, does not make it true.

52 Hazel Meade May 26, 2015 at 12:02 pm

WTF are you talking about? The ACA mandates that employers pay for their employees health insurance. They are actively penalized if they don’t.
It didn’t break the link, it made the link formalized law.

53 Dain May 26, 2015 at 1:45 pm

“The ACA mandates that employers pay for their employees health insurance.”

Not if they define them as independent contractors. The amount of abuse in the Bay Area around that term is enough to turn one into an angry socialist.

54 Jay May 26, 2015 at 3:10 pm

Define “abuse”, I’m sure the companies wouldn’t call it that and if the alternative is those jobs wouldn’t exist in that area then that wouldn’t be the word I would use to describe it unless laws were being broken.

55 JonFraz May 28, 2015 at 3:25 pm

The IRS has some pretty detailed and strict regulation on that. Most employees cannot be so defined.

56 Slocum May 26, 2015 at 2:17 pm

“…The ACA broke that link”

I don’t think that’s going to be the result at all. Employees whose income is high-enough to be above the ACA subsidy-levels are going to cling to employer-provided insurance even tighter than before. Why?

1. Exchange plans without subsidies are a much worse deal than pre-ACA individual plans (higher costs, narrow networks).

2. ACA exchanges cater to older, sicker, poorer customers — it’s a bad risk pool to be in if you don’t fall into those categories.

3. Employers who self-insure are exempt from some ACA taxes & mandates. And more employers may move to self-insurance plans to gain these exemptions for themselves and their employees.

57 prior_approval May 26, 2015 at 9:55 am

‘The doctors are fighting a losing battle’

Not with trade treaties like TPP, they aren’t. American doctors have been remarkably successful at ensuring their more than twice as large income compared to European doctors living in comparable economies remains completely beyond the reach of international free trade agreements. Which TPP isn’t, of course.

58 Cliff May 26, 2015 at 10:15 am

Well, to be fair the average American makes twice as much as the average European as well

59 Moreno Klaus May 26, 2015 at 4:00 pm

Huuuh… loool

60 JWatts May 26, 2015 at 8:37 pm

Median European Union household income: 15.4 K Euro’s

http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=ilc_di04&lang=en

Medain US household income: $51.9K => 38.9 K Euro’s

http://en.wikipedia.org/wiki/Household_income_in_the_United_States

61 Ted Craig May 26, 2015 at 10:04 am

Rural communities have a very hard time finding doctors, so this makes sense. Actually, they have a very hard time finding doctors’ wives who are willing to move to the middle of nowhere.

62 Hopaulius May 26, 2015 at 10:32 am

Yes, because all family doctors are either heterosexual men or lesbians.

63 Ted Craig May 26, 2015 at 12:25 pm

No, but this is a real problem. Sorry if it doesn’t fit your narrative.

64 Ted Craig May 26, 2015 at 12:25 pm

Also, how many gay men aspire to live in small town America?

65 steve May 26, 2015 at 8:02 pm

Absolutely it is a huge problem. Our medical group covers a wide range of facilities, including some small rural hospitals. I have better luck getting people to drive to these places (over an hour each way) than I do getting them to move to these places. OTOH, I have been inside the local high school.

Steve

66 Beliavsky May 26, 2015 at 10:16 am

It should not take 4 years of expensive college study before you go to medical school for 4 years. Letting nurses do more is a good idea, but the supply of doctors could be increased if the path to becoming a doctor was not needlessly long and expensive. Other countries do not have a 4+4 system to become a doctor.

67 Rahul May 26, 2015 at 11:21 am

+1.

Anyways this is one small step in the right direction.

68 Nathan W May 26, 2015 at 1:31 pm

They need all that background in basic sciences to be able to properly understand the studies they need to be able to interpret in order to understand how the body works and the chemistry/biochemistry of what’s going on with the drugs (even though a lot of research is still lacking, often, in HOW the drugs work, and there is often a large degree of trial and error).

I took a few undergrad courses which were primarily populated by pre med students, and so am somewhat familiar with the sorts of stuff that a lot of premed students taken, and I’d hate to think that a doctor would skip out on much of any of the education they were getting in Life Sciences. Then again, there is the argument that med schools should also be recruiting from more diverse fields, but those students will have HUGE learning curves in the more sciency stuff.

69 anon May 26, 2015 at 1:40 pm

It’s also a weeding out process. Premed courses are extremely competitive. This is not to say a 4 year degree, with all of the additional coursework and requirements is necessary.

70 Pshrnk May 26, 2015 at 9:05 pm

YOU CAN’T SAY “weeding out process.” on MR. SAY SIGNALLING !!!

71 Nathan W May 27, 2015 at 2:52 pm

If so, doctors would be just as effective if they started their residency straight out of high school. But without third year human physiology, which they cannot understand without second year microbiology and biochemistry, which they cannot understand without first year chemistry … they wouldn’t have a clue about anything.

Signalling is an interesting theory, and may well be VERY relevant in quite a lot of industries, but throughout all of these courses, as I struggled to memorize insane amounts of information, I never questioned the teaching and evaluation methods, because as opposed to the social sciences where there is time to hit the library, I wouldn’t want to have a doctor who didn’t have most of this information firmly at their fingertips.

72 A Definite Beta Guy May 26, 2015 at 4:42 pm

Doctors have no f’in idea how drugs work. Go talk to a pharmacist.

73 Pshrnk May 26, 2015 at 9:05 pm

Pharmacists often don’t know either.

74 A Definite Beta Guy May 27, 2015 at 10:40 am

Agreed. The years of schooling provided marginal benefit, not worth the hundreds of thousands of dollars in additional education.

75 Jon May 26, 2015 at 10:43 am

There is already a machine that can substitute for anesthesiologist.

The future of medical care will involve a cadre of experts developing software that trained technicians will use to guide the diagnosis and treatment of patients. Instead of going to a doctor, you will go to a nurse or PA who will input information (or hook you up to the devices that input the information) and follow the instructions of the program in prescribing future tests and treatments. Doctors will either focus on the cases the machine can’t handle (e.g. manage complicated surgeries with the help of the machine) or help with the emotional aspects of the treatments.

The question is how much entrenched interests will use the regulatory mechanisms, lack of cost transparency, and moral hazard (e.g. insurance or government reimbursements) to slow this.

76 Dude May 26, 2015 at 10:55 am

Lots of opportunity in this space. Telemedicine is another way to increase the productivity of the healthcare industry.

http://www.wired.com/2015/04/the-ux-of-telemedicine/

77 Pshrnk May 26, 2015 at 11:42 am

Yea telemedicine! ….When was the last time you smelled alcohol on your patient over the telelink? The last time you handed a tearful patient a tissue over telelink? Etcetera

78 TMC May 26, 2015 at 9:36 pm

..smelled alcohol… Or on your doctor!

79 Dude May 26, 2015 at 10:03 pm

Really? Jeebus, what FUD.

Telemedicine is already used and it is only going to grow in the future as the technology improves.

80 Blake May 26, 2015 at 11:39 am

Ah yes, the “machine that can substitute for anesthesiologist.” Much the same that a pack of band-aids substitutes for a heart surgeon. Seriously, one of the big innovations toted up by the media was that it could measure your oxygen level! As if we didn’t have machines doing that for decades!

81 Jon May 26, 2015 at 11:43 am

As I recall it can make more measurements and adjust dosages so that certain procedures that used to require an anesthesiologist in the room only require one to be nearby and on call. It is also only for a limited set of use cases; so of the restrictions are likely there to protect the entrenched interests.

82 steve May 26, 2015 at 8:05 pm

It also costs about as much as an anesthesiologist. It become cost effective only in large GI centers.

83 anon May 26, 2015 at 1:14 pm

You have no idea what you are talking about, do you? The anesthesiologist keeps the patient alive when shit goes south…the surgeon doesnt have the skill set and the surgeon is occupied with the surgery. Anesthesiologists are some of the most skilled critical care people in the business. If I were going to get a serious surgery, I would absolutely make sure there was a skilled anesthesiologist there in the room.

Typical economist opining about things outside their scope of knowledge.

84 Dude May 26, 2015 at 10:06 pm

I’m gonna place a long bet that us technologists are currently working on improving the productivity of anesthesiologists. And by “improving the productivity”, I’m saying “make them less necessary for the whole process”.

85 carlospln May 26, 2015 at 5:51 pm

“There is already a machine that can substitute for anaesthesiologist”

You 1st.

86 looking closely June 3, 2015 at 3:10 pm

>>There is already a machine that can substitute for anesthesiologist.

Bull@#$.

Show me the machine that can place a nerve block or intubate a patient.

.

87 jseliger May 26, 2015 at 10:51 am

“The doctors are fighting a losing battle,” said Uwe E. Reinhardt, a health economist at Princeton University. “The nurses are like insurgents. They are occasionally beaten back, but they’ll win in the long run. They have economics and common sense on their side.”

A couple years ago I wrote “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school,” and it’s become by far my most popular post. In it I wrote this:

Primary care docs are increasingly going to see pressure on their wages from nurse practitioners for as long as health care costs outstrip inflation.

A lot of would-be doctors don’t realize these issues; if they did, I think we’d see less pressure on med school and even more PAs and NPs than we do now.

88 Rahul May 26, 2015 at 11:26 am

We should just stop letting doctors control how many new doctors we train.

89 anon May 26, 2015 at 2:04 pm

Yes, let’s let policy makers, without any knowledge of medicine, decide. The pre-med requirements, >3.7 GPA in difficult course work, board exams, lengthy training, research output, etc are really just ways of restricting the labor supply. They do not at all select for the type of people who are qualified to cut into your skull and remove a tumor.

In fact, I think we should get rid of MD licensing requirements completely. Let’s just let anyone with a bottle of snake oil treat patients.

90 Fallacy Detector May 26, 2015 at 2:12 pm

This one’s easy, straw man.

91 anon May 26, 2015 at 2:34 pm

Increase supply, decrease quality. Nice try.

92 Fallacy Detector May 26, 2015 at 2:36 pm

Zero-sum; fallacy of averages.

93 anon May 26, 2015 at 2:46 pm

lol no. I think you need to go back to the shop for repairs, troll bot.

94 Bernard Yomtov May 26, 2015 at 3:04 pm

Certainly the requirements should be stringent, but that doesn’t mean that, right now, everyone who can meet the requirements and wants to be a doctor ends up being admitted to medical school.

95 Thomas May 26, 2015 at 4:08 pm

Or that everyone graduating from medical school manages to find a residency.

96 Jan May 26, 2015 at 4:47 pm

It’s the residency spots that are a huge problem. There are plenty of highly qualified foreign physicians who would be glad to practice here.

97 Rahul May 26, 2015 at 10:27 pm

….and plenty of natives who would throw a fit when they hear the word “foreign”.

Doesn’t matter if the foreigner is excising tumors or gathering fruit.

98 looking closely June 3, 2015 at 3:11 pm

Wait until Nurse practitioners start to be on the receiving end of medical malpractice lawsuits.

After all, if they’re “equivalent” to doctors, then they should have equivalent responsibility. . .and liability.

99 ibaien May 26, 2015 at 11:47 am

oh boy, more race to the bottom deregulation. i can’t wait until the US medical system has fulfilled its conservative destiny of becoming concierge care for the rich and urgent care for everyone else. we can still hold our heads high about offering ‘the best care in the world’, as long as you’re a visiting banana republic dictator or a wall street financier.

100 Sam Haysom May 26, 2015 at 2:06 pm

“Banana republic” dictator. Hahah this guy is so old and foggety.

101 Fallacy Detector May 26, 2015 at 2:13 pm

Slippery slope

102 fwiw May 26, 2015 at 10:07 pm

I love you.

103 J Clivas May 26, 2015 at 11:48 am

Did China’s “barefoot doctors” (the equivalent of our nurse practitioners) have “common sense on their side” ?

104 hoonose May 26, 2015 at 11:53 am

As a internal medicine ‘specialist’ for nearly 20 years, then more of an adult primary care generalist for another 20, I have long experience. Medicine has of course changed. As I (and most all generalists) no longer do hospital work, a well trained NP or PA can do 90+% of what I now do in the office.

And as long as they know their limitations and make appropriate referrals, they and their patients can succeed. I know NP/PA’s that are smarter and better clinicians than some MD’s. But these are exceptions.

Can they save the system money?

One needs to understand that the medical provider has huge control over the spending of the HC dollars. From testing, medications, treatments and referrals, the attending primary Doc or NP/PA will be directing the spending of vast sums of money. Moneys way out of proportion to that providers salary/earnings. So the savings with a NP/PA may not be large, and could be non-existent if they spend unnecessarily over the typical MD.

105 Hazel Meade May 26, 2015 at 12:14 pm

That last part would really be solved by injecting some price discipline, by making patients pay more of the cost of routine care. Which is not to say that the NP/PA will provide fewer treatments, but that the prices charged for various treatments will start to align more with reality. So they aren’t chanrging $300 for a 10 minute office visit, for instance. If people care what things cost, prices will be more rational.

106 hoonose May 26, 2015 at 1:00 pm

People don’t generally go to the docs without good reasons. Of course we already have HC insurance premiums, co pays and deductibles to weed out much abuse. But even then this stuff is typically small dollar abuse. This isn’t where the big money is going. The larger money in those cases would be in the testing and treatments if the doc isn’t savvy enough to convince the patient they are not needed.

Then we’ve got so much central control of prices. Few HC providers are in any position to charge $300 for a 10 minute simple office visit. For most docs and patients these prices have been preset at a much lower level.

107 Urso May 26, 2015 at 2:17 pm

“People don’t generally go to the docs without good reasons.”
This is true in my experience. I have a ridiculously good medical plan with comically low co-pays. I never, ever, *ever* go to the doctor. I would if I had to, but I’m not going to go on a lark just because it’s cheap. But according to some doomsayers around here, I should be going weekly and just wasting the doctors’ valuable time.
Now, I suspect this falls apart when you get to old people, who have nothing but time and an unusually high need for doctors’ care. But for 80% of the population it holds true.

108 JWatts May 26, 2015 at 2:50 pm

I think most people only go to the doctor when they need to, but when you are paying your own money (HSA for example) you quickly start asking if a certain procedure is really required and how much it costs.

109 Hazel Meade May 26, 2015 at 3:04 pm

And you quickly start asking why the “retail” price seems to bear no relationship to the price that your insurer actually gets charged.

110 Dan Weber May 26, 2015 at 4:34 pm

Some people see the doctor too much. Some people see the doctor too little.

A system designed to fix one of those problems can make the other problem worse.

111 steve May 26, 2015 at 8:09 pm

“you quickly start asking if a certain procedure is really required and how much it costs.”

Nope. Doesn’t happen very often. HSA patients mostly act like everyone else.

112 Hazel Meade May 26, 2015 at 2:56 pm

That wasn’t my argument.
Even if people have a good reason to go to the doctor, if they don’t care about the price, then there is no reason why the provider needs to set rational prices. I think everyone is aware of some of the absurd pricing you will see on medical bills – things like $500 for “venipuncture” (a blood draw). Insurers tend to reign this in some (if their hands aren’t tied), but the underlying irrationality makes the market dysfunctional for out of pocket customers, and ultimately for insurers too. To a certain extent, the market DEPENDS on having some sort of cash market to allow prices to settle on a rational equilibrium. Otherwise it’s a guessing game as to what the right price to charge for a given procedure is.

113 Hazel Meade May 26, 2015 at 12:01 pm

I want to stop thinking of this in term of political interests for a while and think of it in terms of practicality.
Does it make sense to require 10 years of education to do things like diagnosing UTIs and prescribing birth control pills?
90% of the time, it’s someone peeing in a cup, nurse put a dipstick in, and reads off the results. And most of the time the doctors role is totally pro forma. The doctor really only needs to be there for the fraction of the cases where the symptoms presented are unusual or the medical history raises flags.

Rationally, we ought to be moving towards a system where we aren’t wasting the talents of trained doctors. I honestly don’t care who benefits politically.

114 John Thacker May 26, 2015 at 12:47 pm

California has also legalized pharmacists prescribing birth control, and Oregon is considering it as well.

115 Urso May 26, 2015 at 2:19 pm

Any reason to limit the prescribing authority to birth control, other than “this will piss off the kind of people we want to piss off?”

116 A Definite Beta Guy May 26, 2015 at 4:55 pm

Education of the customer and monitoring and someone to speak to in case of emergency. Pharmacists handing out BC essentially OTC is like handing out concentrated anti-biotic OTC, who the HELL does that?

117 Nathan W May 26, 2015 at 6:31 pm

You can buy antibiotics over the counter in much of the world. But actually that’s a problem because people use it wrong and this contributes to anti-biotic resistance. I am not aware of any similar argument for birth control.

118 Cyrus May 27, 2015 at 12:15 am

There is a reasonable case that birth control hormones have become a water pollutant.

119 A Definite Beta Guy May 27, 2015 at 10:38 am

BC can be used incorrectly and does have side-effect. Really, any maintenance medication requires regular check-up with a medical professional, not the drug dispenser at the neighborhood general store.

120 V May 26, 2015 at 3:05 pm

Since NP services are now reimbursed by law at the same rate as physician services (thanks Obamacare!), the main beneficiaries of this will be large hospital chains who can bill the same with a lower cost input (and potentially more as complex cases will now go through an extra layer of bureaucracy) and not the patient or payor (who pay the same for a less credentialed, knowledgeable service provider.

If we want deregulation, we should deregulate (i.e., let patients go to pharmacists and buy things like antibiotics as in most low-cost HC systems).

Instead we are adding an extra layer of cost for no actual benefit as far as I can see (i.e., physicians will now move into even more expensive specialties and since this is a supply-induced demand market, that is even more problematic)

121 Dan Weber May 26, 2015 at 4:32 pm

There’s good reason to keep antibiotics harder to get than aspirin. But there are probably other things you could use as an example where I’d be happy to support you.

122 Moreno Klaus May 26, 2015 at 4:09 pm

The american health care system is insane… It is not normal that >50% of the adds on TV are for medicines (Is everybody sick in the US???)…. To fix this ,well, you guys could start by emulating the UK system for drug reimbursement for a start…

123 JWatts May 26, 2015 at 8:45 pm

“It is not normal that >50% of the adds on TV are for medicines (Is everybody sick in the US???)….”

You might consider not believing everything you read on the internet.

124 FC May 26, 2015 at 9:13 pm

It’s true of golf broadcasts. Wall-to-wall Flomax and Cialis.

125 Moreno Klaus May 27, 2015 at 5:58 am

I didnt read it , I saw it with my own eyes… (but to be fair i only watched 24h news channels)

126 Nathan W May 28, 2015 at 3:15 pm

“It is not normal that >50% of the adds on TV are for medicines”

I recall last time being in the US and watching TV for maybe an hour once and coming to a similar conclusion.

American ads are the worst. Too loud and too full of BS. It amazes me that people can stand to even watch TV there.

127 looking closely June 3, 2015 at 3:09 pm

If all you need is the equivalent of a Master’s degree to be a “doctor” then why the hell does it take actual doctors 7-10 years to do it?

IE, what’s to stop fourth year Medical students from dropping out of medical school and doing the exact same thing as nurse “practitioners”?

Credentials and training are the same. . .(actually more rigorous for the Medical students).

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