Supposedly, in ancient China, doctors would only charge healthy patients. If a patient was sick, their treatment was free. The incentive was to make sure patients became healthy by the time the doctor returned to the village. If not, the doctor wouldn't be paid the next time, either.

The US doesn't exist in a vacuum. There is nothing preventing the rest of the world from doing the required studies. In fact some of them actually do.

People demand useless treatment more in the US because the drug companies are allowed to promote their products to the public. Only NZ permits this outside the US. The result is "ask your doctor" ads become "tell you doctor" demands. If a doctor is ethical enough to refuse there is nothing to prevent the patient for shopping for a different doctor elsewhere.

Doctors may increase their income by performing services of doubtful utility (especially surgery and chemo-therapy), but writing a prescription for some pills isn't it.

There are so many things wrong with the present system, that singling out doctors is a counterproductive distortion. They aren't the biggest problem. The biggest problems are the imposition of several layers of profit making middle men including insurance companies and benefits managers, etc, the excessive profits and marketing power of the drug firms, the lack of coordinated medical records, and insufficient government support for basic R&D.

Drug firms look for drugs that will make them money, not those that will solve real health needs. The ideal product is one that doesn't cure, but requires continued use for the rest of one's life.

All the incentives to better medical care in the US point the wrong way. To top it off we refuse to believe that other countries do it better and to copy or adapt their systems.

This is the fault of the press, for failing to get the real story out. How about it Ezra, write something about how things work in Canada or France or Japan.

Why do they overprescribe?

Because the price mechanism in health care is broken.

Hm. Maybe I don't understand the compensation structure for primary care physicians. If I go to see my doctor about an issue, he gets paid. Are you saying that if I see my doctor and his treatment is to prescribe me prescription medication, then he gets paid even more than if he advised, "take an aspirin, and gets lots of rest" ? I find that difficult to believe. Perhaps any primary care physicians among the blog readers can chime in.

Don't you get tired of it all, Ezra? Seriously. You're a smart guy. You can connect the dots...don't ever see a common thread in all the problems you talk about...whether in health care or anywhere else?

Don't you see that everything you complain about and cite and call attention to is the product, directly or indirectly, of some "bright idea" you probably would have supported in real time that perverted something that then, in turn, coaxed something along that led to what you're pointing out? Does that not matter? Does it bother you so much that you try to work around it? What gives?

If there are a bunch objects connected by strings and you yank on one string, they all move. And then you have to deal with where the strings get displaced to. Keep it up and the original tug get almost totally forgotten and its effects almost unrecognizable.

Why pretend these predicaments came from nowhere? They all have roots in misguided repeated tugging of the strings.

In this case, even when you seem to give the impression of noticing what I'm talking about, you give no impression of letting it affect your conceptualization of any proper course of action.

That sort of transformation requires a whole lot of evidence, which means funding a whole lot of comparative effectiveness research.

So... how much would it actually cost and let's get started creating legislation to make it happen.

I'm so sick and tired of Klein and Yglesias revealing their ignorance on the "doctors lobby" and the NP/PA issue. They clearly understand neither of them.

Doctors payments account for about 20% of overall healthcare costs. When you take out the overhead and just look at doctors incomes, this number falls to 10% of overall healthcare costs. Pardon me, but I think 10% of total costs is a reasonable partition.

The AMA is about as powerful as a paper tiger. They havent been successful in a single major lobbying issue since the 1960s. Less than 20% of american doctors are AMA members.

Now, this is the part that really pisses me off. I keep hearing Yglesias and Ezra Klein popping off about how "doctors are artificially restricting scope of practice for NPs and PAs."

Thats absolute shit. NPs and PAs can DO ANYTHING A DOCTOR CAN DO EXCEPT SURGERY. THEY CAN WRITE FOR ANY DRUG. THEY CAN ORDER ANY DIAGNOSTIC TEST. THEY CAN START THEIR OWN CLINICS. THEY CAN ADMIT PEOPLE AND MANAGE PATIENTS IN THE HOSPITAL.

So please Matt and Ezra, exactly what power are you going to give to NPs and PAs that they dont already have? Surgery? Because thats the only thing they cant do taht doctors are allowed to do. They can be first assistants though and they are utilized heavily in that role.

I really want an answer, because this thread pops up every 2 months or so, and its always the same bullshit when its clear they dont know what they are talking about.

TELL ME ONE THING A PA/NP CANT DO THAT A DOCTOR CAN DO EXCEPT SURGERY!!!!

Ezra,

I agree with your overall point, but I believe it's misleading to say that "Doctors don't make much money when they prescribe unnecessary antibiotics for colds." It would be more accurate to say that doctors don't make any money from prescribing medications. The doctor is paid for the visit and the evaluation, not for the medications prescribed, labs ordered, or imaging referrals. That's true for any sort of primary care physician, anyway. Surgeons,on the other hand, do have an incentive to do as many surgeries as possible.

In addition, since both you and Yglesias have made this point repeatedly, I would be interested to see any evidence you have that increasing either the number or practice scope of ARNPs and PAs would decrease health care costs. While it may or may not be a good idea, I don't believe it would have an appreciable effect on costs. Do you have a study proving this point?

> If there are a bunch objects
> connected by strings and you
> yank on one string, they all
> move. And then you have to
> deal with where the strings
> get displaced to. Keep it up
> and the original tug get
> almost totally forgotten and
> its effects almost
> unrecognizable.

And if you sit perfectly still and don't tug on any string one of two things happens:

1) you die of starvation (or coronary artery disease is someone brings you food and water)

2) you are strangled by the strings being pulled very powerfully by others - typically wealth Republicans since they have the resources to hire others to pull the strings they want pulled and keep on pulling them until they have the section of the web with the juiciest flies all rolled up and under their control. After which you, again, starve to death.

So what DO you recommend?

Cranky

it's misleading to say that "Doctors don't make much money when they prescribe unnecessary antibiotics for colds." It would be more accurate to say that doctors don't make any money from prescribing medications. The doctor is paid for the visit and the evaluation, not for the medications prescribed, labs ordered, or imaging referrals. That's true for any sort of primary care physician, anyway. Surgeons,on the other hand, do have an incentive to do as many surgeries as possible.

Good post. Ezra and Matt repeat these same ridiculous talking points over and over again when they make these threads every couple of months.

Where doctors increase income is the number of invasive procedures they do, NOT the number of meds they prescribe. Also, docs dont make money on referrals to specialists or imaging referrals. Medicare and insurance companies dont pay docs for medications or referrals.

In addition, since both you and Yglesias have made this point repeatedly, I would be interested to see any evidence you have that increasing either the number or practice scope of ARNPs and PAs would decrease health care costs. While it may or may not be a good idea, I don't believe it would have an appreciable effect on costs. Do you have a study proving this point?

Its true that NPs and PAs make less money than doctors, but where Matt and Ezra get it wrong is that they assume that cost savings is transferred to consumers.

Insurance companies charge the same premiums and copays regardless of whether its a PA or MD providing the service. They essentially pocket the extra money.

Let me repeat this again: PAs and NPs can already do everything a doctor can do except surgery. This myth that their scope of practice is being restricted somehow needs to die.

We doctors are part of the problem, but health care cost problems are multifactorial. New tech and pharm are probably the biggest drivers. End of life costs are drive mostly by families wanting everything done, while they do not have to pay for any of it. Much of the costs ascribed to health care are really social costs e.g. obesity, drug and alcohol abuse and trauma.

Would better studies help. You bet. Would they cost a few hundred million? HA! Do not be so naive or deceptive. Also, remember that things change very quickly. We need new studies all the time.

If you really want to reduce costs, first make sure that you leave room for incentives so that you dont end up with the problem of providers not wanting to work. Next, work on the social ills we have. Next, track where all the money goes and adjust pricing accordingly e.g. there is a current boom in joint replacement surgery. Tighten the criteria for replacement or slightly reduce fees until you achieve the desired effect. Next, tort reform. Defensive medicine is not the primary cause of increased costs, but it is low hanging fruit. Next, standardize all paperwork, especially billing. When your billing person has to deal with 15 different forms, it is very inefficient. Computerize records so that repeat tests are not performed. Lots of other stuff but there is a start for you.

Steve

HMOs capitate. How's that working out?

I think we ought to try fee for service with a neutral review of treatment of efficacy before giving someone (else) a financial incentive to deny treatment. Yes its better to have doctors, who are in the same room as the patients and have to see them suffer, responsible for rationing instead of insurance companies. But better yet would be someone knowledgeable about the research you describe who gets neither more nor less money when treatments are performed.

Almost forgot, small businesses in my area have complained that their health insurance costs have doubled every 5 years. If my income had doubled every 5 years I would not be sitting here typing. It would be one of my 5 naked blonde bimbos typing for me. ;-)

BtW, I love the guild idea. I think it would be great to form guilds again and have good old fashioned guild wars. How much worse could it be than what we have and probably a lot more entertaining.

Steve

Cranky,

No you don't starve. Just as your are pretty much not at a lack of anything that doesn't get its strings beyond recognition.

Nobody pulls these strings outside of government. Don't ever lose sight of that. I don't favor them being pulled on behalf of anyone.

BTW, you have a greater chance of being a republican than I do. I would never. So save the partisan stuff for someone who cares.

Moreover, the questions I'm asking Ezra are being asked because I know he gets what I'm talking about. You, not so sure.

As for what I do, any of these problems requires a respect for basic forces they are ALWAYS in play whether you like it or not. The question is how you influence them and at what cost and risk to provoking other problems...which is precisely what I am talking about here.

Doctors, in general, do not naturally "overprescribe"...just as any other multifaceted service is never consistently oversold to you unless you want it to be with full knowledge and consent of and responsibility for what you are doing.

This is partly a moral hazard problem, partly a price mechanism problem and surely others as well.

As with most poorly regulated markets, forces run amok in health care from their natural course.

Doctors have a legal incentive to avoid NOT prescribing any possibly helpful drug. See: lawsuits. On the consumption side, customers have no incentive, nor does the market, to produce more clarity in product information. Patients generally are not interested in price, cost/benefit, trade-offs or any discerning details because they have no incentive to do so. Drugs are the easiest sale in the world because doctors have various legal and financial incentives to prescribe them. Putting these incentives together is toxic. On the consumption side, patients are insulated from cost so they have little incentive to discriminate or seek better information...and as result...there's little incentive to provide that transparency since people in general are not looking for it enough.

I think from here, you can see where the proper direction is.

Quick comments.

1) When HMos were trying to cut costs, through capitation and utilization review in the mid-90s, costs plummeted. They were beaten back by angry patients.

2) There are indirect ways that doctors make money through pharma prescriptions, but as I said, it's not much, and it's not why they prescribe. But the gifts and trips and speaking fees from pharma companies and reps don't hurt.

3) It's not about what RN's can do (though that's limited -- they can only write prescriptions without a physician in 17 states, they have to be overseen in 25 states, etc), it's about the efforts doctor's groups make to ensure they don't get a foothold on the frontline of care. This isn't an unknown fight, so I'll let you do your own googling, but for an example of the mindset, you can start with this article.

Fortunately, there have been several comments debunking the bunk in this blog entry. As a primary care physician I do not make more when I prescribe more treatments (whether it's physical therapy, prescription meds, etc.).

This may indeed apply to surgeons and invasive specialists, which is why any talk of health care reform needs to separate what needs to be done for primary care and "partialist" care. This is where the evil physician's lobby focuses its resources. I do not know a primary care physician that is a member of the AMA, and I do not know of a lobby organization looking out for me.

Regarding NPs and PAs, even though my state is complaining about the severe shortage of primary care physicians, I am considering giving up my 80-hr a week practice, which nets me $110-120K a year and taking an advertised PA position at the local hospital that pays $80K per year for three 12-hour shifts in the ER per week.

Props to Joe Blow, david bart, and particularly robertdfeinman above - comments are right on, I believe.

I'm a nephrologist - taking care of people with (mostly) chronic renal failure, including those on dialysis, so in some ways I'm speaking from the trenches.

As others have said, (most) MD's don't get paid for prescribing meds, though some get paid for delivering them, as in oncologists infusing chemotherapy and my field giving erythropoietin and other agents to patients on dialysis. In fact, the cost of epo is one of the biggest drivers in the (federally-subsidized) cost of dialysis care. But it's the cost of the *drug* not the delivery. In fact, reimbursement for hemodialysis care is at levels reached in the mid-1980's, and flat since then.

As noted above, Medicare, and by extension private insurance, pay for *procedures* not thinking or good outcomes. In this way gastroenterologists (think all those mandated colonoscopies), surgeons, radiologists (particularly inteventionists) make bank, while subspecialties like general internal medicine, endocrinology (incl diabetes care), and infectious disease, while unarguably valuable, oriented toward analysis and prescription of medications, are at the low end of the compensation ladder.

Thus Ezra'a call for breaking the horrid monolith of the MD guild as the salvation of American health care is laughable. An no, replacing MDs with (vastly) less trained versions of nurses and other assistants is not a "solution" either. In my experience such practitioners are useful and appropriate *adjuncts* not independent operators (notwithstanding their wide-ranging opportunities for independence as detailed in a previous post) - such practitioners can very quickly exceed the bounds of their competence, sometimes with disaster.

I think many of these calls for reform, switching from (alleged) reward for intervention to reward for health, capitation, etc, miss the point the medicine is frighteningly inexact. Our understanding of disease is horridly incomplete as is our ability to intervene. Each patient is different, and none really resemble the one in the textbook. Assuming that there is some precise intervention for a precise diagnosis, and further that all patients that we put in such defined pigeonholes behave exactly interchangeably, is quite wrong. Medicine is a minefield, with many, many opportunities to cause harm, and through no incompetence or malice. I find it laughable that a guy as smart as Ezra buys this notion that paying MDs less, or incentivizing their non-delivery of care, is any sort of 'solution' at all.

There are indirect ways that doctors make money through pharma prescriptions, but as I said, it's not much, and it's not why they prescribe. But the gifts and trips and speaking fees from pharma companies and reps don't hurt.

This is reminiscent of the earlier discussion about Amtrak. Yes, some spending on Amtrak might be wasteful, but it's such a small amount that I can't be bothered to care. Drug reps taking docs out for dinner is hardly high on my list of concerns. Improve the monitoring of prescribing patterns, and the problems will resolve themselves.

I appreciate the response, Ezra.

I agree - pharm reps and their marketing tactics are very bad. I'd be in favor of almost anything that would eliminate their influence, but I fear the constitution gets in the way of some of my ideas. I do believe that trips are no longer allowed, and speaking fees would only affect a small number of physicians. I would also suggest that pharm reps tend to influence which meds (ie, the more expensive ones) are prescribed rather than whether meds are prescribed or not. I assume by "indirect ways" you're referencing something to the effect that new prescriptions often create the need for additional return visits. Fair enough.

Regarding the third point, you're right that doctors attempt to limit the role of PAs/NPs. They're as territorial as any group. Again, though I question whether there is any cost savings to be had by increasing the role of PAs/NPs. I doubt the per unit cost of care delivered by NP vs MD is that much less, going by salaries of experienced NPs vs family physicians. And the type of care under discussion - outpatient visits for checkups, simple acute issues, basic med management - is not that expensive to start with. The article you linked to did not have any evidence of cost savings, and the ones I found on PubMed (sorry, I don't know how to link to them) were equivocal as well.

The argument that we just need more primary care providers, and we should just take them where we can get them, is better but still not convincing. We absolutely need relatively more PCPs and fewer specialists (PAs and ARNPs like to work in specialty clinics too, by the way, because they get paid more). I'd note that Family Practice, Internal Medicine, and Pediatric residency spots never fill completely, even with D.O.s and International Medical Grads. Everyone is aware, on the other hand, of how competitive Dermatology, Orthopedics, etc are. I think the answer is pretty clearly increasing the reimbursement rates for office visits and counseling relative to procedures. I believe these are decided by an advisory group to Medicare, and private insurers base off that. I guess I find it strange that, given how much you write about medical errors, unnecessary tests, and poor quality of care, one of your major suggestions is to have more providers with less training.

And thanks, by the way, for blogging on Saturday afternoons.

> Nobody pulls these strings
> outside of government. Don't
> ever lose sight of that. I
> don't favor them being pulled
> on behalf of anyone.

Yeah, AT&T is having a remarkable lack of success in forcing the Congress to do its bidding on immunity for violating the law and Constitution. Same remarkable lack of success that Disney had in changing the copyright laws to its preference, that the oil industry has in using the US Army and Navy as its police force, etc. No, large concentrated economic interests _never_ get to pull any strings in our world.

Cranky

We need to back up again and look at how much of healthcare spending goes into doctor's pockets.

Its 20% of total healthcare costs. However, that includes overhead stuff like clinic utilities, malpractice insurance, etc.

If you take that out and look at just money that goes into doctors incomes, its a paltry 10% of overall costs.

So I'm confused as to why its imperative to focus on that 10% as the key to lowering healthcare costs. You could cut doctors incomes in half and overall healthcare costs would only go down by 5%. Thats not exactly something I'd get excited over.

Regarding the third point, you're right that doctors attempt to limit the role of PAs/NPs. They're as territorial as any group.

How is that, exactly. Let me remind you that it was DOCTORS who started both the NP and PA movements.

Let me say this again. NPs and PAs can write for any drug, do any procedure (except major surgery), write any orders, and order any tests that a doctor can order. They can start their own clinics, they can admit patients to the hospital and serve as the sole attending who carries them during their stay.

So again, what is it that you are going to give to them that they cant already do? Even Ezra knows its probably not wise to let a nurse replace a neurosurgeon. They can already do everything else.

Ezra, did you even read the article you cited about NPs? Let me post a snippet:

# CAPNA is run exclusively by nurse practitioners.

# The nurse practitioners have hospital admitting privileges, a move Pearson acknowledges is "cutting edge."

# They are listed on the provider panels of managed care organizations (MCOs) and reimbursed at the same rate as physicians. Few advanced practice nurses in the country have received such recognition from commercial insurers.

How exactly are NPs going to lower costs again? This article is 10 years old, and what it also doesnt say is that NPs are moving towards mandatory doctoral programs.

I seriously doubt the NPs are going to take a pay cut, especially after they start granting doctoral degrees.

Another item to note about that article. In New York State, NPs are allowed to run everything solo (which is what CAPNA is doing). Yet healthcare costs are much higher in NY than in other states. So its not true at all that NPs having unrestricted practice will magically lower healthcare costs.

Joe Blow's and Ezra Klein's posts are equally dumb.

PAs are supervised by doctors, therefore they can't just pickup and start their own practice.

NPs are not even allowed to practice medicine in most states.

So Joe Blow doesn't know what he's taking about either.

Nobody pulls these strings outside of government. Don't ever lose sight of that. I don't favor them being pulled on behalf of anyone.

So John V is a rabid libertarian. That explains why so many of his comments make him sound like he's stoned.

Here lets simplify it down for Joe Blow to one Concrete example. Here in Washington A NW can NOT write any presciption. The script can only be signed by the a physician. Across the river in Oregon they can write them but they must be overseen by a physician. It varies by state.

As far as capitating.. If/when you make pay based on a given measure, companies will work to optimize that measure, whatever it is. Thats pretty basic.

If you base it on the number of patients through the door, thats the metric you're going to raise. It may well come at the cost of bedside manner, quality of care, and convenience.

10% of care.. yes their base income may account for 10% but they are the decision makers that a much greater %age of spending depend on.

People on both sides of this argument, the drs and the 'experts' are being either disingenuous or cant se the forest for the trees here. Ive watched it from the inside of the office, but working for a different industry.

It is true that MOST doctors dont get paid more for more prescriptions. But the pharma reps dont talk to MOST drs, they talk with the head doctors for a given office or group. They reward sales with free samples, free medical equipment, free computers, free trips, optional speaking engagements. These things are valuable..

"Doctors have a legal incentive to avoid NOT prescribing any possibly helpful drug. " Thats crap, its called standards of care. If the new drug doesnt make it into that they are in most states not legally obligated to prescribe it.

They CAN, and a good doctor probably would if it was indicated and generally accepted treatments werent working, but they dont have to prescribe the newest most expensive thing as often as occurs.

Thanks EK for at least trying to make an effort here. Part of the problem is this is a good format for argument (often fruitless) but not one for actually solving anything. Maybe a wiki updated with your latest thoughts on problems and solutions would be better suited to solutions instead of just bickering.

oops. . NW = NP in my post above.

Ezra,

An excellent post. It'd been a while since you've written a meaty health care post, but you did good here.

Not much to add generally, I agree with 99% of what you wrote.

One small point-- the need for comparative effectiveness boards has only a little to do with concerns about "pure" or "biased" information, its much more about that industry studies frequently don't design their studies to answers the questions needed to "compare effectiveness."

PS. If you invest appropriately in health IT, you could do retrospective comparative effectiveness for a fraction of the cost. Another reason why health IT is so important.

Actually two other thoughts:

So too would increasing the supply of doctors

This one is wrong. Supply, in this case, drives demand. So without some constraints on the total volume of health care utilized, increasing supply will not lower prices, it'll simply increase demand. Look to Dartmouth for more on this, but simply put-- the $ per capita in a region correlate pretty highly with the doctors per capita in that region.

And since neither the doctor nor the patient pays much per marginal unit of care, their incentive is to leave the encounter feeling good, not save money. So paitients ask and doctors prescribe. More expensively, doctors help families pursue heroic measures for their dying relatives even as they know they won't do much good. This isn't a guild protecting itself so much as human nature pointing in a possibly harmful, and definitely pricey, direction.

Which is why I push consumer-directed health care and surprised you don't embrace the concept more fully, politics aside. You won't be able to fix it with capitation-type reimbursement and increased knowledge via a CEB. There are many things that are very well-studied that are either 1) not done even though should be, e.g. immediate treatment in ER for complaint of heart attack. 2) continue to be done when they shouldn't, e.g. hysterectomies. Giving patients a composite, easy-to-understand rating of health providers can help guide them to the ones providing clinically effective care, and some cost-sharing will point them towards more cost-effective care.

I just want to throw something out there. Doctors may be a bit more open to a change in the method of compensation if we could do something about the crushing cost of Medical school. I don't think MOST doctors do it because they want to get rich, MOST have a calling and want to help patients. But after being saddled with a mountain of debt, many are forced in to a specialty so they can actually have a chance to pay of their debt.

I guess my point is that if we could get rid of the massive up front costs of becoming a doctor, doctors might be willing to make a little less. Especially if this allowed there to be more doctors, allowing for the doctors to have a better work life balance ( Kind of like the doctor that posted above who was considering giving up his practice, and to take less money, in order to work more reasonable hours.)

@jason K
It could be.. If your optimistic about human nature I suppose. :p

It would be a fairly easy experiment to test out through government action. ..or you could do it with a small subsidized study perhaps?

There are also programs like they have for ANH (alaska native health) Where a doctor can work in that system for a given number of years (I think its 5) and get their school debt forgiven. (Are there other programs like this?)

So perhaps those docs should be polled to see what their leanings are, and something could be gleaned from that.

This is a fairly common concern thats raised. But I would counter that most graduates nowadays are faced with a mountain of debt. I think a lot of them will face either an inability to pay, or default. Every other profession isnt showing such a stratospheric rise in pricing.

Why is it primarily medical care? In my opinion is that its an abuse of their position. Doctors are the only ones able to participate in their industry, so they keep prices artificially high. To pay off school? Perhaps initially. However once thats done and the porches and mansions start being purchased, thats no longer a good argument to make.

@jason K
It could be.. If your optimistic about human nature I suppose. :p

It would be a fairly easy experiment to test out through government action. ..or you could do it with a small subsidized study perhaps?

There are also programs like they have for ANH (alaska native health) Where a doctor can work in that system for a given number of years (I think its 5) and get their school debt forgiven. (Are there other programs like this?)

So perhaps those docs should be polled to see what their leanings are, and something could be gleaned from that.

This is a fairly common concern thats raised. But I would counter that most graduates nowadays are faced with a mountain of debt. I think a lot of them will face either an inability to pay, or default. Every other profession isnt showing such a stratospheric rise in pricing.

Why is it primarily medical care? In my opinion is that its an abuse of their position. Doctors are the only ones able to participate in their industry, so they keep prices artificially high. To pay off school? Perhaps initially. However once thats done and the porsches and mansions start being purchased, thats no longer a good argument to make.

Cranky,

in your last post, you quote me as saying:

Nobody pulls these strings
> outside of government. Don't
> ever lose sight of that. I
> don't favor them being pulled
> on behalf of anyone.

And then you respond:

Yeah, AT&T is having a remarkable lack of success in forcing the Congress to do its bidding on immunity for violating the law and Constitution. Same remarkable lack of success that Disney had in changing the copyright laws to its preference, that the oil industry has in using the US Army and Navy as its police force, etc. No, large concentrated economic interests _never_ get to pull any strings in our world.

What's your point then with respect to what said? You said it to me for a reason. What reason would that be? Is what you said supposed to be a "Ah-HA!" or "Gotcha!" rebuttal to anything I said?

If anything, you simply showed a real life example of something I oppose while ignoring everything else I said.

And Tyro,

after quoting the same thing that I said that Cranky did, you say:

So John V is a rabid libertarian. That explains why so many of his comments make him sound like he's stoned.

First of all....rabid?? Seriously, man. There's nothing rabid or extreme in what I said. You simply choose, I would assume, to either not agree with position or not care for its relevance in such issues. I'm not too sure which.

BTW, your condescending remarks about being me "stoned" in order to say that I don't approve of special interests distorting markets for their own narrow gain do you no credit.

It’s misleading to say doctors get paid for the visit and not the prescription, because getting a prescription is normally the reason for visiting. I didn’t go to urgent care a month ago for the doctor’s objective analysis of the brownish phlegm I was hacking up; I went there for some Zithromax! I can sit at home and suffer for 2 weeks just fine on my own, without a doctor’s advice, thanks.

In my opinion, most prescription drugs should literally be over the counter. Pharmacists should sell them from inside a pharmacy, using their expertise and judgement. But the prescription should just be the doctor’s advice what to buy, not the legally mandated permission slip that it is today.

Jeepers, you must have been out late last night. Cranky, much?

Tear that old doctors' guild down! I'd be with you, if only I could figure out what the hell you're talking about. The AMA is a useless lobbying group (group insurance and AMA Visa cards too!) that controls nothing and to which few of us belong. Go ahead and get rid of them. The states license MDs just like they license lawyers, CPAs, barbers, and structural engineers. A little regulation can be a good thing. Dean Baker obsesses on foreign medical graduates. FMGs are, of course, forced to get visas to work in the US -- either regular visas or J-1 visas available only to MDs (it's actually easier to emigrate to the US as an MD than a non-MD.) Once a FMG has a visa he or she has to pass all the same licensing as the US graduate plus -- here it is, the big obstacle -- the TOEFL. That's why there is a growing number of foreign graduates working in the US. If you could explain what you mean by "guild", it would help make your case. I'll happily write my (useless Republican) congressman a tart letter demanding that it be elimiated.

I've worked my entire career with NP/PAs. I don't see much resistance to working with them among other docs. That don't offer much of cost savings though. Currently Medicare compensates them at 85% of what an MD makes, so switching to an all NP/PA workforce and sending the MDs off to work as baristas would save a whopping 1.5% of overall healthcare costs. Wee-haa! You're on to something there!

Seriously, you've overstated the problems with angioplasties and back surgery, both of which are appropriate under certain conditions. The angioplasty study to which you are alluding was for a very specific condition -- not all angios. There is also a very distinct desire on the part of many people (my patients anyway) to be "cured" rather than "take a pill for the rest of my life". I agree that there is a lot of unnecessary medical care, but the cause is a lot more complex than you claim. I really, really don't get a single penny of compensation for a prescription, referral, or most diagnostic test (other than the occasional shave/punch biopsy of a skin lesion). In fact, most of the time those things actually cost me money since I work in HMO-rich southern California. Indirectly, I make money by keeping a patient rather than causing them to change doctors when I refuse their requests. I do admit to using the crappy plastic pens when that's all that's handy, but I prefer the nicer ones with our own logo. I personally choose not to accept bagels, sandwiches, and dinner "lectures" from reps -- just like I'm sure you choose not to accept free books from publishers (my husband who works in a different industry loves going out to lunch with vendors). We don't get offered the stuff dave b claims other than the samples and those are greatly appreciated in the working-class neighborhood where I work.

We can't expect to fix the structural problems in the delivery of healthcare in this country unless we first identify real problems instead of blaming "guilds", plastic pens with drug logos, and inflated claims about physician incomes.

just like I'm sure you choose not to accept free books from publishers

Hmmm... good point. Ezra? Any chance you hold yourself to the same professional standards you're expecting from doctors? We'll overlook the "advertising pays some of my salary" element, and just focus on whether you forego profession-related freebies...

But JBean, the rest of your post is the classic, reasonably rationalized response from physicians who don't believe they are a major part of the problem.

A few points:

The AMA is a useless lobbying group (group insurance and AMA Visa cards too!) that controls nothing and to which few of us belong. Go ahead and get rid of them.

Well, the AMA are the ones who have a close-to-100% success rate in preventing cuts to Medicare physician reimbursement. In fact, they are in the process of doing that again during this past week, as Reid has put another 18-month reprieve on the schedule for a vote. They've also successfully minmized the degree of compensation linked to performance over the past few years as well. The AMA may be declining in influence and membership, but they are a major obstacle to reform.

inflated claims about physician incomes

It isn't about inflating claims of PCP incomes. Its about the actual facts that radiologists are making $300,000 to 500,000 when everyone knows that imaging is overutilized leading to billions wasted in health care expenditures. Its not the physician incomes that are the problem per se-- its the complete lack of accountability for quality, combined with that as long as compensation is linked to volume, a 1.5% decrease in physician compensation is a 6-10% decrease in total system costs.

I think JBean hits the nail on the head and shows why any kind of health care reform is going to be so incredibly difficult; as I've posted before it will only happen when we get to a crisis of some sort.  Case in point, back surgery.  You can cite all the studies you want about how useless lumbar fusions are, but if you have an actual patient with severe back pain they want SOMETHING DONE.  They are just not willing to "live with it" even if living with it is by far the best course of action.  Multiply this actual patient by 300 million actual americans and you can see the tremendous difficulty nay impossibility of satisfying everyone.  Add to that the ease of demagouging the issue, and reform is impossible.  That's one of the (many) reasons I couldn't stand John Edwards, with his demand for liver transplants for comatose lymphoma patients if it makes a good soundbite.  If you want to control costs, someone, or more the point, just about everyone is going to get less. 

John V, you claim to have a very simple solution to all the problems we are facing in the health care system.

That is why you are obviously wrong, and there is little point listening to you.

At a baseline level, "not pulling any strings" obviously entails not providing any health insurance coverage for the poor, not having government licensing for doctors, and not having government review of drug safety. So there are three indefensible aspects of your proposal that you can get working on.

Oh, and BTW, Celebrex is still on the market, vioxx and bextra were withdrawn.

Brooksfoe,

where's the simple solution I'm claiming?

I don't see it.

obviously entails

No. It doesn't.

You conflate caveats with absolute assertions.

I guess this advice is more useful than I thought.

In psychiatry the incentive is to prescribe as much medication as you possibly can. It keeps the patients nice and sedated and it's sooo very much cheaper than providing the care they really need. Unfortunately, in the end the high cost of the medications themselves, and the cost of recurrent hospitalizations, and the cost of lost productivity far outweigh what it would have cost to pay a competent professional to provide that expensive comprehensive treatment.

It’s misleading to say doctors get paid for the visit and not the prescription, because getting a prescription is normally the reason for visiting. I didn’t go to urgent care a month ago for the doctor’s objective analysis of the brownish phlegm I was hacking up; I went there for some Zithromax! I can sit at home and suffer for 2 weeks just fine on my own, without a doctor’s advice, thanks.

Here's a nice illustration of the problem. Most of the time bronchitis doesn't need to be treated with antibiotics. If this person doesn't have COPD or asthma or some other comorbidity or an infiltrate on a chest x-ray, he or she is not going to get better any faster with antibiotics. Woe to the doc who tries to explain that to this person though. It's a hell of a lot easier to just make him/her happy and write the Rx. Note the request for the name brand rather than the generic, too.

unnecessary hysterectomies
You're 40, you've been bleeding heavily 2 weeks out of 4 for the last two years, you can't tolerate hormones or they don't work, iron is nauseating and constipating, you feel constantly fatigued and have to work full time while taking care of a home and family. This may last for ten or more years until menopause. Or maybe you're 60 and can't walk more than 100 yards without your uterus sliding out of your vagina and you leak urine continuously and the pessary that supports your prolapsing uterus pinches and hurts with every step and smells and you're embarrassed by the Depends you have to wear. Or maybe your husband has to tie your shoes because your uterus is several cm above your belly button with fibroids and you can't bend over because you are effectively 8 months pregnant permanently. Or perhaps you need daily narcotic medication for your chronic pelvic pain, you stay home from work for 2-3 days every month with your menses due to pain, and you can't have a bowel movement easily because of the narcotics and the fact that your bowel is matted to your uterus with endometriosis. None of these women would die without a hysterectomy, but I bet that they would all have a much better quality of life after one. Now Ezra, maybe it's hard for you to picture yourself in one of those conditions, but imagine what it would be like if you were married to one of these women and you hadn't had sex for 2 years ....

(N.B. There are some new procedures like endometrial ablation and uterine artery embolization which might help the first woman, but neither procedure existed a decade ago.)

It isn't about inflating claims of PCP incomes. Its about the actual facts that radiologists are making $300,000 to 500,000 when everyone knows that imaging is overutilized leading to billions wasted in health care expenditures.
Generalized medicine is underpayed with respect to European pay-scales and specialties are overpayed. Plus, we just plain, flat train too many specialists. A cheap solution to the healthcare crisis is to stop training so damn many specialists. Use the money that is saved in training to improve generalist training, possibly even extending IM residencies to a 4th year.

There also has to be some sort of "tort reform". If general guidelines say that people under 55 with new onset back pain and no fever, etc. don't need an x-ray until they've had 6 weeks of pain, then someone who doesn't get that x-ray until 6 weeks shouldn't be able to sue me for "delay of diagnosis". If guidelines say that you need a Pap every year until age 30 and every 1-3 years after that and I tell you that, then you shouldn't be able to sue me if you don't get your Pap for a few years and then get a diagnosis of cervical CA. If your kidneys are failing from diabetes and hypertension and I manage your electrolytes and fluid balance until your kidney function deteriorates to the point that you need dialysis, you shouldn't be able to sue me for "failure to refer appropriately". And so on and so forth.

A lot of unnecessary imaging is patient-demand driven. Like the person above with bronchitis, everyone who gets an ankle, knee, or back injury these days wants an MRI. I have explained approximately 3 million times that MRI is a great tool for surgical planning, but I have yet to see one cure a sore joint. Rarely is that effective. I have to admit that I take a perverse little pleasure when somebody comes in with 4 days of ankle pain and asks for a referral to "an orthopedics doctor". I always look horrified and say, "You want to see an orthopedic surgeon?". They always respond that they don't want to see a "surgeon" just "an ortho doctor". I, of course, continue to refer to the orthopod as "a surgeon". Sometimes it works.

Oh yeah, and thanks Ezra for posting on the weekend. The nanny software at work lets me read a limited number of blogs including this one, but it won't let Captcha through, so I have to hold my tongue. Very frustrating.

PAs are supervised by doctors, therefore they can't just pickup and start their own practice.

NPs are not even allowed to practice medicine in most states.

Wrong on both counts. PAs can start up their own clinics with 99% ownership. They just need one MD partner for the 1% minority ownership of the practice. NPs need zero physician supervision or collaboration to start up their own practice.

If by "practicing medicine" you mean stuff like scripting drugs, ordering tests, doing procedures (sans surgery), admitting patients to the hospital, and covering their stay in the hospital, then well you are dead fucking wrong with your second comment too. NPs can do all of those things.

Again, give me specific examples of what NPs/PAs are NOT allowed to do. You have non clue what you are talking about.

Here lets simplify it down for Joe Blow to one Concrete example. Here in Washington A NW can NOT write any presciption. The script can only be signed by the a physician. Across the river in Oregon they can write them but they must be overseen by a physician. It varies by state.

Liar, liar pants on fire. Washington and Oregon recently changed their laws:

http://www.acnpweb.org/i4a/pages/index.cfm?pageid=3465

Also, it's worth pointing out on the subject of income that the docs who are at the highest end of the income spectrum are the plastic surgeons and dermatologists doing cosmetic work, the reproductive endocrinologists doing IVF, and the ophthalmologists doing Lasik. All that crap should not be included in the cost of health care -- it's merely conspicuous consumption in a very rich society.

There are also programs like they have for ANH (alaska native health) Where a doctor can work in that system for a given number of years (I think its 5) and get their school debt forgiven. (Are there other programs like this?)

yes, there are other programs like this, but they are MASSIVELY underfunded. Most of those health programs have so many applicants that they have to reject the vast majority of them.

HPSP is a good example. Its a nationwide loan forgiveness program for doctors who agree to practice in rural areas. Last year, 75% of applicants were rejected because there were insufficient funds.

These programs would help a lot if they were actually funded appropriately.

think a lot of them will face either an inability to pay, or default. Every other profession isnt showing such a stratospheric rise in pricing.

Why is it primarily medical care? In my opinion is that its an abuse of their position. Doctors are the only ones able to participate in their industry, so they keep prices artificially high.

Both points are untrue. Doctors incomes overall have been flat since the mid 1980s, yet healthcare costs have exploded during that time frame. Doctors incomes are not the reason behind the cost increases.

Secondly, you once again ignore PAs and NPs and pretend they dont exist. The example you gave of Washington state has INDEPENDENT NP CLINICS RUNNING RIGHT NOW WITH ZERO DOCTOR INVOLVEMENT. Dont believe me? I'll give you some addresses and phone numbers to call and verify.

It’s misleading to say doctors get paid for the visit and not the prescription, because getting a prescription is normally the reason for visiting. I didn’t go to urgent care a month ago for the doctor’s objective analysis of the brownish phlegm I was hacking up; I went there for some Zithromax! I can sit at home and suffer for 2 weeks just fine on my own, without a doctor’s advice, thanks.

In my opinion, most prescription drugs should literally be over the counter. Pharmacists should sell them from inside a pharmacy, using their expertise and judgement. But the prescription should just be the doctor’s advice what to buy, not the legally mandated permission slip that it is today.

WTF? Its not misleading, its a fact. Doctors dont get reimbursed by insurance based on how many meds they script. Thats the facts, jack.

How do you know that brownish phlegm is not a PE? Are you willing to bet your life that its not a PE with zero medical training? BTW, can you give me the 3 classic signs of a PE so I know you can tell the difference?

While you're at it, maybe you could give me the PORT score ratings for determining PNA management. You do know what those are, right?

I'm all for making more drugs OTC, but antibiotics should NOT be included in that group. The reasons for that stance should be obvious.

david bart,

If a patient goes to a doc, waits 2 hours in the waiting room for a 5 minute visit with the Doc who tells them they need to stay home and rest for two days and drink lots of fluids the patient will think they didn’t do anything and find another doctor. Doctors prescribe needless medicine so they have appeared to have done something. When the doctor next door will give the patient what they want it’s hard to say no. Maybe we should allow doctors to prescribe placebos?

Docs make a fortune to refer to the same practice or in house lab. Countless studies have shown markable and unjustified increase in ordering lab test when the doctor runs them in house. That is why numerous insurance companies signed exclusive deals which required all lab work be ran through one company, i.e. LabCorp or Quest. In Las Vegas APL made a killing going after the business of doc owned labs. Was easy to show self funded plans and carriers how they where getting robbed.

Joe blow,

“Insurance companies charge the same premiums and copays regardless of whether its a PA or MD providing the service. They essentially pocket the extra money.”

That statement is something as clueless and stupid as Ezra says. You have no concept how underwriting works. You don’t charge a premium based on the type of provider seen. If you meant to say they reimbursed the same you might be correct with some carriers but that is changing. Most American’s are covered by plans that are experience rated, if claims are lower then premium will be lower the following year.

Rite Aid, CVS, and Wal Mart are all opening clinics now, besides charging a fraction of what a doctor does the largest impact they will have is access. You can walk in off the street and receive affordable care. This will decrease utilization of ER and Urgent Care, hopefully catch some illness sooner, decrease the spread of illness due to treatment. To say none of that will impact total cost of health care is ignorance or bias.

Steve,

What 15 forms do billing staff deal with? Unless they are Medicare/Medicaid mandated there should be only an 837. Federal law requires EVERY payor accept the 837, if the problem is government maybe we need less not more. Do you live in CA or NY? Or MA those are the only states I have seen where premium has doubled like that…we can thank small group reform for that, not the doctors or insurance companies.

Liberal Scientist,

Why would someone insure against thinking or good outcomes? Insurance is designed to make whole or reimburse you for unknown or time uncertain events, it’s a very inefficient financing method. It’s because politicians and the market forced them into such unnatural behavior we have some of the problems we do.

Mark,

A Llcense to practice Medicine is a privilege by law, it can be conditioned on not accepting any gifts or compensation from Pharma. Insurance Real Estate, Attorney and other licenses all have similar restrictions. It could be accomplished by a federal law and in place by end of year if the politicians wanted do.

The clinics that hire PAs and NPs have substantially lower cost from what I have seen. GO to WalMart.com or Walgreens and look at their pricing schedule, considerably cheaper then billed charges I see from any MDs. Office space is cheaper, malpractice is probably a fraction. There is no way an MD can economically treat a scratch or minor cough.

Wisewon,

90% of medical claims flow through 2-3 EDI clearing houses, couple million and some common sense you can have more data then any scientist would know what to so with. Scrub the personal data, publish to the web and let the world have at it. Even a government program couldn’t turn that into more then a couple hundred million one time cost with minimal ongoing.

We should forgive a portion of Med School debt, after we cut the fat out of the med school tuition to start with , after doctors serve a couple years in public clinics. Preventative care, immunizations, and other such care of a consumptive nature should not be covered by insurance. It adds minimum 20% to the cost. All of those types of service should be delivered free of charge via public clinics by new docs on flat salary.

Scott,

Back surgery isn’t bad in of its self. It’s the bloated cost from off label hardware the devise rep chooses to stick in people. We started seeing 2 day stay back surgeries with 90+ bills. We started clamping down and asking questions, who ordered the off label screws? Hospital says the Doc the Doc says they don’t know. Come to find out the Manufacturer Rep standing in on the surgeries does. We know they where bogus charges because when we denied 70K of the bill no one appealed and the member never heard a word about it. Now we write all of our plan docs to specifically exclude such unapproved hardware and the average cost has plummeted back to what it was. Every couple years we see the same scams and abuse of the system;
In office lab work
X Rays
Sleep Apnea/Studies
Back Surgeries
Not all doctors are bad, but to many of them are active or complacent in fraud and abuse.

JBean,

I don't disagree with anything you say, just that you ascribe too much weight to your points (besides tort reform, we agree on that one, as you probably know) and are too passive in giving some blame to physicians.

At the end of the day, 1) physicians are the primary decision-makers of health-care 2) more importantly, they do a terrible job of actually practicing evidence-based medicine and keeping-up with best practices. Relative to the level of quality possible, physicians aren't doing a good job. They are doing the wrong thing 50% of the time (meaning not they are pursuing the wrong path on the differential diagnosis, but that they have the differential correct and their diagnostic or therapeutic choices aren't supported by the data). 50% is not acceptable. See Don Berwick at Harvard for more on this (I think his number is actually 45%).

Wisewon,

90% of medical claims flow through 2-3 EDI clearing houses, couple million and some common sense you can have more data then any scientist would know what to so with. Scrub the personal data, publish to the web and let the world have at it. Even a government program couldn’t turn that into more then a couple hundred million one time cost with minimal ongoing.

Nate,

That would be a start, but claims data does not provide sufficient information to really be able to do this effectively. So there would be a few quick wins by doing what you suggest, and may actually be a good step to convince others that health IT is important. But claims data isn't sufficient.

As as aside, two weeks ago Medicare and FDA started down this path for improved adverse event reporting. Its an excellent idea, another that would benefit tremendously from health IT, and would change the calculus of risks and benefits for drugs altogether. A topic for another time.

Docs make a fortune to refer to the same practice or in house lab.

You have no clue what you are talking about. Federal Stark laws make this practice patently illegal.

The clinics that hire PAs and NPs have substantially lower cost from what I have seen. GO to WalMart.com or Walgreens and look at their pricing schedule, considerably cheaper then billed charges I see from any MDs. Office space is cheaper, malpractice is probably a fraction. There is no way an MD can economically treat a scratch or minor cough.

You dont know what you're talking about. Multiple studies have shown that overall healthcare utilization does NOT shift from doctors to NPs/PAs, it just adds to the total utilization bill.

When there are minute clinics around, it doesnt decrease the burden on doctor-centered practices, all it does is drive up the overall cost of healthcare. People go to their regular doctor AND the walmart clinics.

What you dont understand is that doctors and NPs/PAs dont compete against each other. Doctors themselves dont compete against each other. Instead they drive up demand. Thats why NYC has the highest doctor/patient ratio in the country and STILL has the highest healthcare costs per capita in the country (even after adjusting for cost of living indices).

Healthcare cant operate like a free market because the consumer doesnt know what they need. Therefore you could flood NYC with 10 billion doctors and costs would actually go up, not down.

Here's a nice illustration of the problem. Most of the time bronchitis doesn't need to be treated with antibiotics.

Yes, but the commenter said that he was coughing up brownish phlegm, which doctors generally regard at in indication of a bacterial infection. At a certain point after you've been to the doctor with the same issue, you begin to know what you have and what you need.

Note the request for the name brand rather than the generic, too.

I could not tell you the generic name of most drugs I've ever been prescribed, but when I walk into the pharmacy, I'll ask for the generic version if it's available. That's mostly because my co-pay for a generic is so much lower.

When there are minute clinics around, it doesnt decrease the burden on doctor-centered practices, all it does is drive up the overall cost of healthcare. People go to their regular doctor AND the walmart clinics.

Why? Going to a doctor is a substantial waste of time. I really have no interest in seeing my doctor when I need a simply prescription medication for a problem, however, right now, they're the gatekeepers for such things. If they weren't the sole gatekeepers, I wouldn't go to them; I have better things to do than drive to his office.

Why? Going to a doctor is a substantial waste of time. I really have no interest in seeing my doctor when I need a simply prescription medication for a problem, however, right now, they're the gatekeepers for such things. If they weren't the sole gatekeepers, I wouldn't go to them; I have better things to do than drive to his office.

Before minute clinics, if people got sick after hours they simply didnt go to the doctor and instead waited it out.

Now, when they get sick after hours, they go to the minute clinic. However, they still go to their regular doctor for all other healthcare needs.

Therefore, the overall utilization INCREASES.

People dont use minute clinics as PCPs, they use them strictly for after hours complaints when their regular doctors office is closed.

Why? Going to a doctor is a substantial waste of time. I really have no interest in seeing my doctor when I need a simply prescription medication for a problem, however, right now, they're the gatekeepers for such things. If they weren't the sole gatekeepers, I wouldn't go to them; I have better things to do than drive to his office.

BTW, if you are going to your doctors offices regularly for bacterial infections, then you have a problem with your immune system and should probably have some bloodwork done. The way you describe it as a routine practice is troubling.

P.S. If its only drugs you want, you dont need to see a doctor at all. There are plenty of online foreign pharmacies that dont require a script at all and will ship direct to your house.

Next time, order your Zithromax online from a Euro or South American pharmacy. Its at least 50% cheaper than state-side too. No doctors script and a lot cheaper, its a no-brainer.

Yes, but the commenter said that he was coughing up brownish phlegm, which doctors generally regard at in indication of a bacterial infection. At a certain point after you've been to the doctor with the same issue, you begin to know what you have and what you need.

Its not that clear-cut. Bronchitis = no antibiotics needed. However, brown phlegm can also be a sign of PNA or a PE, and those 2 definitely require treatment. You have to listen to the lungs with a stethoscope to make the distinction between bronchitis and PNA.

Joe Blow writes:

Again, give me specific examples of what NPs/PAs are NOT allowed to do.

One example of what they're not allowed to do is be my primary care physician. I've chosen an NP as my PCP everywhere I've worked and lived until my current job; my insurance, a major plan that's top-rated by US News and JD Power, doesn't allow me to select anyone but an MD as my PCP. I don't know what the thinking is behind this, but it's hard to imagine that the rule isn't in doctors' interests, which makes me suspect that it's a result of their advocacy.

Whenever something that isn't so simple I can diagnose it myself comes up, I'm immediately packed off to a specialist; if this weren't true, it would make a lot more sense to me to insist that an MD be my gateway to medical care. Which makes me wonder about Mark's objection to Ezra's call for more NPs/PAs:

The argument that we just need more primary care providers, and we should just take them where we can get them, is better but still not convincing. We absolutely need relatively more PCPs and fewer specialists (PAs and ARNPs like to work in specialty clinics too, by the way, because they get paid more).

As my health care works now, I can absolutely imagine a PA doing a totally fine job as a PCP. But if we start relying more on people with less training for primary care, doesn't that kind of guarantee that my health care will continue to work that way, with office visits consisting either of writing a scrip or making a referral?

I don't think my doctor overprescribes because she wants to make me feel better; I think she overprescribes because she works in a practice where the assumption is that a drug is the first line of treatment, followed by specialists and procedures and supposedly more appropriate drugs. The structure of the practice itself reinforces this assumption; her day is scheduled so that she could hardly take the time to do more diagnostics if she wanted to. Obviously, if we want to allow doctors to see fewer patients in a day and do more complex diagnostic work, we have to train more primary care providers and increase reimbursement for office visits, but I think we could also use a cost built into the system for making a referral or writing a prescription. I don't mean money, of course, though I love the ancient Chinese solution of paying doctors only for health and not sickness. But a time and effort cost, perhaps; what if doctors had to schedule a consultation themselves when making a referral, or submit a written treatment plan explaining their reasons for prescribing a drug? What if the length of visit required in such cases was increased for prescribed sets of diagnostic tests, so that patients wouldn't come in for a prescription unless their complaint was serious enough to make it worth the time they'd spend? My point isn't that PCPs should be punished for making referrals or prescribing, but that we need to do more signaling to both doctor and patient that this happens when a situation has become serious, and that time and observation will be the default treatment for most complaints.

Ezra, you struck a sour note here. What a confusing thread of comments. As a simple-minded primary care physician, let me see if I can sum this up.

If I email my lawyer a question, and he spends 15 minutes researching the answer, I will get billed $75 ($300/hr). When I recently asked a TV repairman to come out, he spent 15 minutes looking at my set, told me how expensive it would be to fix it, and charged me $90 for the evaluation. I think it is very reasonable for me, as a professional, with years of training and trailing debt, to make a similar professional income. The problem is, if I want to make $75 for 15 minutes of work, because of the costs inherent in the whole health care system I have to charge $150 for that visit. The administrative burden to actually get paid the $75 is unbelievable. I have 3 different software systems, and two specific personnel, that I have purchased, leased, or hired in order to bill an all-powerful corporate or government entity (as opposed to the actual customer) that has the ultimate say in how much I am reimbursed for that work. That is ridiculous. Add to this, for every 10 minutes I spend in front of a patient, there is another 30 minutes worth of non-reimbursed work that is done (referrals, documenting the visit to ridiculous standards, prior authorizations for drugs, handling phone calls and emails for questions, etc.).

This is probably not a popular view with my colleagues, but I would prefer a system in which primary care physicians were employed, salaried, with pay varying according to quality and efficiency, med school debt forgiven to some degree (perhaps based on where you decide to practice), and with malpractice immunity similar to what government-employed physicians have at present.

If the potential salaries are generous and on par with what other professionals make, and the after-hours and weekend workload is reasonable, and the debt is less a worry, then there wouldn't be a primary care shortage and the care that is provided would be more consistent, more cost-effective, and more in line with standards of care.

One example of what they're not allowed to do is be my primary care physician. I've chosen an NP as my PCP everywhere I've worked and lived until my current job; my insurance, a major plan that's top-rated by US News and JD Power, doesn't allow me to select anyone but an MD as my PCP. I don't know what the thinking is behind this, but it's hard to imagine that the rule isn't in doctors' interests, which makes me suspect that it's a result of their advocacy.

I'm calling BS on this. Name your insurance company and I'll find an NP or PA on their roster listed as a PCP.

Its well established--the vast majority of insurance companies recognize NPs/PAs as PCPs.

but I think we could also use a cost built into the system for making a referral or writing a prescription.

Uhh, we've seen this movie before and its called the HMO. HMOs in the mid 90s were infamous for having gatekeepers "approve" specialist referrals. Guess what, the model failed because americans are selfish greedy motherfuckers who refuse to take NO for an answer. Havent you been paying attention to the latest health insurance ads? Virtually all of them include some nugget about "getting access to any specialist you want without a referral"

more importantly, they do a terrible job of actually practicing evidence-based medicine and keeping-up with best practices. Relative to the level of quality possible, physicians aren't doing a good job. They are doing the wrong thing 50% of the time (meaning not they are pursuing the wrong path on the differential diagnosis, but that they have the differential correct and their diagnostic or therapeutic choices aren't supported by the data). 50% is not acceptable. See Don Berwick at Harvard for more on this (I think his number is actually 45%).

I'm assuming you are referring to the RAND study which showed that patients only get half of the healthcare they are supposed to get.

What you gotta remember is that most of these "quality EBM" studies are based on bullshit metrics that have absolutely nothing to do with improving health or mortality.

For example, one of the metrics in the RAND study was control of blood sugar for diabetics within a certain range of normal. Well it turns out thats absolutely IRRELEVANT to improving diabetes mortality.

NY Times link:

http://www.nytimes.com/2008/06/07/health/research/07diabetes.html?ref=health

You need to know what the real "best practices" are before you trump them as some kind of laudable goal. Turns out that most of the RAND metrics were absolute crap that had absolutely nothing to do wtih improving morbidity or mortality.

wisewon:
I don't disagree with anything you say, just that you ascribe too much weight to your points (besides tort reform, we agree on that one, as you probably know) and are too passive in giving some blame to physicians.

At the end of the day, 1) physicians are the primary decision-makers of health-care 2) more importantly, they do a terrible job of actually practicing evidence-based medicine and keeping-up with best practices. Relative to the level of quality possible, physicians aren't doing a good job. They are doing the wrong thing 50% of the time (meaning not they are pursuing the wrong path on the differential diagnosis, but that they have the differential correct and their diagnostic or therapeutic choices aren't supported by the data). 50% is not acceptable. See Don Berwick at Harvard for more on this (I think his number is actually 45%)

Oh, I'm not saying that poor powerless doctors, buffeted by demanding patients are innocent, just innocent of all wrongdoing here. If you get paid for a procedure and you are going to make someone happy by offering them the procedure, it's pretty easy to convince yourself that you are providing good patient care. I try to walk a fine line between making patients happy and behaving ethically. I spend a lot of time trying to explain why tests aren't required. OTOH, we have an absolutely awful situation where I work. The hospital across the street was purchased by an entrepeneurial doc who aggressively soaks insurance. He has an in-house coterie of docs (all from his native country which would surprise Dean Baker) and they do over the top workups for everyone they admit. We encourage our patients not to use that hospital, but if we or they call 911, they get transported to the nearest hospital. The hospital is also very aggressive about "balance billing".

As the above commenter with bronchitis/pneumonia/TB/pulmonary embolus/lung cancer/sarcoidosis/pneumonitis/thrombocytopenia/nasopharyngeal cancer proved, there is a strong component of patient demand for inappropriate treatment. On the liberal blogs, it is quite fashionable to assert that no one wants "too much" care, however both personal experience and formal studies show otherwise. Unless we acknowledge that and build some kind of patient-borne financial incentive into the system, the problem won't get fixed. When the insurance companies started tiered co-payments for generic vs. branded drugs, I saw patients abruptly switch from preferring branded meds to requesting generics.

I see two more strains of conflicting beliefs here: it's cheaper to use providers (i.e. NP/PA) with less training and the problem is that primary care docs aren't adequately trained. I agree with both statements although the cost savings on non-physicians is minimal. It's not clear to me at all that using less well trained providers is going to improve medical care (yes, but if we use EMRs....)

PCPs provide routine screening exams. Those can be easily done by NPs. But screening guidelines are not as cut and dried as it sometimes seems. They change, they can be quite complex, they are often in conflict, they often require patient cooperation and multiple doctor visits for titrationn, and they may not be appropriate for all patients.

Look at PSA as an example. The AUA says do them, the USPSTF says don't. As a freshly graduated doc, I patiently explained the ins and outs for a couple of years. In that time, I had exactly one patient decide not to have the test done. I, of course, made sure to carefully document the decision so that I couldn't be sued if he ever developed prostate CA in the future. Then I just started ordering the test routinely. People actually used to get angry with me and even occasionally file complaints with my employer when I tried to customize their screening tests. My patient satisfaction scores went from middling to high when I gave in and started ordering shotgun screening tests and wearing a white lab coat. The shotgun tests also saved my upfront time, detected the occasional asymptomatic non-problem (more CYA!) and decrease my anxiety about malpractice suits (look up why Terry Schiavo's OB lost a $1M judgement).

The other problem with using less well trained providers is that diagnosis is a hard skill. I was a code monkey before medical school and it was clear to us that not everyone can learn how to code. Diagnosis is a similar skill. Shotgunning tests is easier and faster than taking a stepwise approach. Do a round of tests to rule out common and dangerous conditions and then bring the patient back for a more exotic workup. Surprisingly, that just upsets the patient rather than impresses them with your care for the insurance company's money. In medicine, you are trying to rapidly make often complex diagnoses based on data that is at best very fuzzy and very noisy.

Many non-HMO patients also bypass primary care physicians. They view specialist care as "better" care. I had a new patient recently from the east coast. She brought records from the endocrinologist who treated her hypothyroidism, the rheumatologist who treated her fibromyalgia, the gastroenterologist who treated her irritable bowel, the pulmonologist who treated her BOOP (exotic!), and the OB who did her Paps. It made my head hurt.

professordarkheart:
I'm not sure if you were agreeing with me or not - but I agree with you that providers with less training will tend to make more unnecessary referrals and write unnecessary scrips. Uncertainty leads to covering your bases. For what it's worth, though, I do believe that many of these referrals/extensive work-ups are driven by patients as much as physicians. I guess that's an excuse as much as a reason, but it is a real pressure on physicians.

Getting back to the origins of this thread, I would still be interested in any research that suggests increasing the number of PA/NPs would decrease health care costs or improve outcomes. The articles I've found so far do not support the claim.

Before minute clinics, if people got sick after hours they simply didnt go to the doctor and instead waited it out.

Now, when they get sick after hours, they go to the minute clinic. However, they still go to their regular doctor for all other healthcare needs.

Therefore, the overall utilization INCREASES.

I would really have to see a statistical study bearing this out before I believe this. My pattern of illness is:

get sick.
Wait for it to clear up.
If it does not clear up after more than a week or two, see a doctor.

I don't see why I would visit a clinic on short-notice that I wouldn't do otherwise, since it's not for at least a few days that a condition requires the attention of a medical professional, in the first place.

If there were a minute clinic involved, then the "see a doctor" part would be replaced by "go to the pharmacy clinic." I can't foresee circumstances in which, if my need to see a doctor were replaced in some instances, I would see him anyway. It's conceivable that I might visit the clinic more often, making my total number of medical visits increase slightly, but the doctor would definitely get visited less.

BTW, if you are going to your doctors offices regularly for bacterial infections, then you have a problem with your immune system and should probably have some bloodwork done.

I was speaking in general about the 1 time a year or so prescription medication might be necessary, not necessarily about antibiotics, specifically.

Keep in mind that even some very basic medications that are now over-the-counter used to be prescription-only until very recently.

I find this "crush the guild" business completely exacerbating. A few points about the psychology of healthcare spending may help clarify things:

1) If you create giant incentives for sub-specialty care (i.e. generous reimbursement for procedures), and giant disincentives for primary care (i.e. poor reimbursements for office visits, horrible paper work, and the threat of a lawsuit if aggressive diagnostic testing is not pursued) than obviously you're going to have more specialists, less generalists, and an incentive for more aggressive work-ups. The "doctor guild" has nothing to do with this, and in fact does not exist on any practical level. Instead there's a lot of smart young doctors making their career choices based on the incentives described above.

2) End-of-life care is a huge problem. There was a recent article on long-term care in NEJM that estimated the costs will triple over the next couple decades. They are already 10% of the total. This doesn't even include ICU care, a large percentage of which is futile. The point is, cutting doctor salaries won't help you with these enormous costs, because they result from basic misunderstandings amongst patients and their families about what is and what is not appropriate care. A broader discussion about what we're willing to do for people as they age and become sicker is needed.

3) Doctors have enormous fixed costs. There's 8 years of school with >100k debt on average. Then there's residency and fellowship, with > 80 hrs/week of training for lousy pay. Then, when they become attendings, the cast majority continue to work 60+ hrs per week in exchange for a salary somewhere between 100k-200k per year. How on earth can anyone expect to maintain a supply of decent young doctors without at least preserving the existing income, particulary for primary care docs and non-invasive specialists?

Supposedly, in ancient China, doctors would only charge healthy patients. If a patient was sick, their treatment was free. The incentive was to make sure patients became healthy by the time the doctor returned to the village. If not, the doctor wouldn't be paid the next time, either.

That sounds like a great deal to me. I'll recruit all the young healthy people into my practice. Then I can go golfing 50 hours a week and rake in the money and I dont even have to provide any services since they're healthy and dont need anything from me!

As for the sick people, then can fuck off because my practice only has room for healthy people.

Ghinson,

How do you feel about a system where you treat a patient, a patient pays you, and no one else cares what happens between the two of you nor ask you to complete any forms? High deductibles and insurance companies that only sell insurance.

In the corporate world when a business buys insurance for a known event or an expense they plan on having it’s called fraud and gets people fined and sent to Jail. Our government is aggressively targeting fake “insurance” policies as not really being insurance, see GE and AIG. Then they turn around and tell the general public to do the exact same thing with their personal health insurance.

As a PCP how many patients do you treat that would really go bankrupt if they had to pay you direct and we cut the insurance companies and government out of it? How much could you lower your charges if you got rid of 2 out of 3 software packages and an employee?

I'd be okay with that (and have considered doing that several times). It does seem strange to pay $1400/mos for a family health insurance policy to cover the $55-125 visits to my office. We don't expect our car insurance to pay for oil changes. But, I recognize that if I see someone for a $100 preventive medicine visit, and order tests. The bill for the labs, from the local hospital could easily be $500. If we can extract primary care doctor office visits out of the whole broken system, then the high deductible policies and cash at the time of service plan would work. But as it is, it is hard to separate the two.