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| No. 60 | 
Aug 06, 2009, 08:12 AM
 Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by MAISY, RN-ER  What do you do? Where are you in healthcare? You haven't answered that question.
Understand residents aren't going into primary care due to the MONEY! We get that, so who will fill the gap? Your answer is better reimbursement-of course. That's no surprise to me, meanwhile the gap and access to care will widen as entities fight over not paying and even less primary care physicians graduate. Good idea.
As for you constant harping on comparing apples to oranges, Geez give it a break! Unless specially trained no NP or PA is operating on the same level as a PMD! You have a one track mind. Re read my posts....as for the residents I'll stick to my own and my fellows experiences. I work in a large urban ER and see alot!
And again, I never said DOCTORS care only about the disease-reread. You said residents should work, I said their response to disease process and PRACTICE - to me, is like a little kid clapping their hands over a new toy-"oh, goody let's see what happens if......" However, I see the evidence of patient MISUNDERSTANDING EVERY DAY! Whose job is it to check meds, make sure that the patient understands their diseases and their processes, understand what the outcome may be for non-compliance, or be there to answer questions? If it's not the doctor then who? I see that mess every day! Worse, is not having anyone to see.
Do you really believe that NPs and PAs can't work an urgent care type situation? Or as part of a team?
As for loan forgiveness, perhaps someone will forgive all of my loans for myself and my college aged kids....but no, I make too much money....as would a doctor! OR, I submit that medical school loans be given to young people that want to work primary care and will do so in poor areas for a set number of years providing loan forgiveness. I think this should be available to all health professionals....why not?
M
Maisy,
We all appreciate your candor and obvious passion for your work. But you seem to have tremendous difficulty answering simple questions that are posed to you.
1) How will an individual NP be a cheaper alternative to a primary care MD/DO with respect to individual patients? Not the system as a whole, not with respect to preventative medicine. How will one NP seeing a patient in clinic be a cheaper alternative to a primary care MD/DO seeing a patient in clinic if NPs are striving for equivalent reimbursement?
2) Should 4th year medical students be allowed to practice medicine independently as well, since they have potentially more training at that point than their NP colleagues at similar places in training? If so, that could be a way to fill in the primary care gap. I bet there would be a fairly large cohort of medical students/new medical grads who would be willing to forego 3+ years of measly residency salary for a primary care doctor's pay.
 | | Advertisement Sponsored Links | | | | No. 61 |
Aug 06, 2009, 02:09 PM
Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by MAISY, RN-ER What do you do? Where are you in healthcare? You haven't answered that question.
Understand residents aren't going into primary care due to the MONEY! We get that, so who will fill the gap? Your answer is better reimbursement-of course. That's no surprise to me, meanwhile the gap and access to care will widen as entities fight over not paying and even less primary care physicians graduate. Good idea.
As for you constant harping on comparing apples to oranges, Geez give it a break! Unless specially trained no NP or PA is operating on the same level as a PMD! You have a one track mind. Re read my posts....as for the residents I'll stick to my own and my fellows experiences. I work in a large urban ER and see alot!
And again, I never said DOCTORS care only about the disease-reread. You said residents should work, I said their response to disease process and PRACTICE - to me, is like a little kid clapping their hands over a new toy-"oh, goody let's see what happens if......" However, I see the evidence of patient MISUNDERSTANDING EVERY DAY! Whose job is it to check meds, make sure that the patient understands their diseases and their processes, understand what the outcome may be for non-compliance, or be there to answer questions? If it's not the doctor then who? I see that mess every day! Worse, is not having anyone to see.
Do you really believe that NPs and PAs can't work an urgent care type situation? Or as part of a team?
As for loan forgiveness, perhaps someone will forgive all of my loans for myself and my college aged kids....but no, I make too much money....as would a doctor! OR, I submit that medical school loans be given to young people that want to work primary care and will do so in poor areas for a set number of years providing loan forgiveness. I think this should be available to all health professionals....why not?
M
The only people capable of filling in a physician's role are physicians, not nurses, not NPs, not DNPs, not PAs. With years and years of clinical time practicing medicine (NOT nursing), they can be more similar to a physician.
Stop assuming that when someone says NP/DNP training is inadequate to practice independently that they're insulting your intelligence or worth as a person. If say a doctor knows more about medicine than a plumber, is that true? Yes. Does that mean the the plumber is an idiot while the doctor is smart? No. But does it mean that the medical knowledge a doctor has is significantly greater than that of a plumber? Absolutely. Should the plumber cry about it now? Similarly, when I say that NP/DNP training is nowhere close to the level of training a physician receives (and this is an absolutely true statement), don't get angry at me and respond by calling me a kid "harping on" about the same thing.
If anyone is harping on about the same thing, it's been you. Your only solution so far to the PCP shortage has been to fill that gap by utilizing midlevels who do not have the same level of training as a physician. As I mentioned previously, the only people who can replace physicians are other physicians. I have offered solutions that would increase the number of physicians who go into primary care rather than midlevels.
A 4th year medical student has more medical training than an NP/DNP does. This is a true statement. I'm sure your years of nursing prior to NP school might help, but it is NOT a replacement for clinical hours practicing medicine. Nursing clinical hours =/= medical clinical hours. To claim otherwise is misleading. There are also several programs that let you get an NP in 3 years without any prior healthcare experience. That's even scarier.
Let a 4th year medical student practice medicine independently. They have a better basic science foundation than midlevels (you can't really argue against this claim) and they have more clinical hours practicing medicine in their 3rd year than the NP/DNP curricula do. So, logic follows that if NPs/DNPs are allowed to practice independently with less basic science and clinical training than 4th year med students, why can't 4th year med students be allowed to practice independently? I will guarantee this will increase the popularity of primary care specialties. Not only will the student save on a year's worth of tuition, they will also be able to start paying back their loans earlier since they don't have to deal with the measly pay of 3 years of residency. Med school is aimed at putting out generalists; that's one reason why specialist training is longer than that of FM/IM/Peds, etc.
Seeing an NP/DNP will not really be cheaper. They already get reimbursed at 80% of physicians' rate by Medicare (if I remember correctly). And they are pushing for equal pay. Why would you pay someone with less training than physicians the same as physicians? It makes no sense.
As for your preventative care statements, there's no guarantee that preventative medicine will save money. It's very possible that preventative medicine will be more expensive in the long-term than what currently exists. Think about it. You have no idea whether or not preventative medicine will actually help the patient or not; it may very well be that the patient, for example, was never going to have a heart attack even if you haven't had him on statins for a decade. Now, there's the expense of the treatment that's been useless in preventing anything. Not only that, even if preventative medicine prevented something and allowed a person to live longer, how much additional cost is it going to be when that person uses up additional medical resources? I'm not at home right now and can't really access journals from where I am but don't obese patients actually save the system money since they tend to die earlier? As harsh as that sounds, it doesn't make it any less of a true statement in the world we live in today.
So your arguments that NPs/DNPs will save money and that preventative medicine is the way to go are not as sound as you seem to think. Now, please don't take everything I've said as a personal insult and respond by calling me names again. I'm waiting for your rebuttal and for you to finally answer the questions I've been asking you, which forpath kindly restated.
| | No. 62 |
Aug 06, 2009, 03:45 PM
Re: Doctor Shortage-Who Should Fill the Gap? http://money.cnn.com/2009/07/16/news...ion=2009071807
This is a very interesting string of posts. I see a ton of good ideas on here. Some of you should go back to the article link above and put your posts on CNN for all the world to read. I am of the opinion that if we leave NP reimbursements at the lower rates and open them up to autonomous practice, we can acheive exactly what we need to in the way of healthcare reform. Physicians continue to ruin our healtcare system. They are very dysfunctional in their behavior and alomst every reaction they have to cost cutting measures has a way of making it worse than it was before. It sickens me to hear someone say that we need physician input in the healthcare debate. They are a huge part of the problem, and furthermore, they exacerbate the issues that we have with big pharmaceutical companies and insurers. I'm not saying that they are all greedy and don't care about patients at all, but for the most part it is true. They have shaped the system in such a way that they can prescribe more, order more and make more, and they want their cut of the profits from non-physician providers too. And guess what, they get it. After all of that, they want us to cry with them about their student loans, which are proportionate to their salaries (why should we feel sorry for them because of that?). They also want us to cry about their malpractice premiums and give them tort reform, when no other profession enjoys protection from malpractice claims. Then they want us to feel sorry for them because they have high overhead. When other businesses have problems with high overhead, they become inovative and figure out a way to cut it. Why can't physicians find ways to use technology to streamline their businesses and cut overhead? Are they just too lazy to do it or too stupid? I am sick and tired of physicians crying about how bad they have it. If they were so bad off, why would banks be knocking down their doors to loan them money when they won't loan other businesses a dime? Physicians have it better than any other group in this country and they make their money from the health insurance premiums that are driving their patients further and further into mountains of debt. Their only solution is, we need to make more money and have the American public pay off our loans for us. This is ludicrous and there are many better solutions that don't involve paying physicians more or training more of them. We need to start to pressure our state legislators to give us autonomously practicing Nurse Practitioners as a start to reforming our system NOW!
| | No. 63 |
Aug 06, 2009, 04:07 PM
Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by mbreaz1 http://money.cnn.com/2009/07/16/news...ion=2009071807
This is a very interesting string of posts. I see a ton of good ideas on here. Some of you should go back to the article link above and put your posts on CNN for all the world to read. I am of the opinion that if we leave NP reimbursements at the lower rates and open them up to autonomous practice, we can acheive exactly what we need to in the way of healthcare reform. Physicians continue to ruin our healtcare system. They are very dysfunctional in their behavior and alomst every reaction they have to cost cutting measures has a way of making it worse than it was before. It sickens me to hear someone say that we need physician input in the healthcare debate. They are a huge part of the problem, and furthermore, they exacerbate the issues that we have with big pharmaceutical companies and insurers. I'm not saying that they are all greedy and don't care about patients at all, but for the most part it is true. They have shaped the system in such a way that they can prescribe more, order more and make more, and they want their cut of the profits from non-physician providers too. And guess what, they get it. After all of that, they want us to cry with them about their student loans, which are proportionate to their salaries (why should we feel sorry for them because of that?). They also want us to cry about their malpractice premiums and give them tort reform, when no other profession enjoys protection from malpractice claims. Then they want us to feel sorry for them because they have high overhead. When other businesses have problems with high overhead, they become inovative and figure out a way to cut it. Why can't physicians find ways to use technology to streamline their businesses and cut overhead? Are they just too lazy to do it or too stupid? I am sick and tired of physicians crying about how bad they have it. If they were so bad off, why would banks be knocking down their doors to loan them money when they won't loan other businesses a dime? Physicians have it better than any other group in this country and they make their money from the health insurance premiums that are driving their patients further and further into mountains of debt. Their only solution is, we need to make more money and have the American public pay off our loans for us. This is ludicrous and there are many better solutions that don't involve paying physicians more or training more of them. We need to start to pressure our state legislators to give us autonomously practicing Nurse Practitioners as a start to reforming our system NOW!
I agree that physicians are a large part of the problem, and I personally know of many egregious examples. That being said, however, if NPs/DNPs become a larger percentage of the healthcare workforce, you will still see the same problems sans meaningful healthcare reform, because nurses are people too, and greed is, unfortunately, pervasive in our species.
We have seen it already to some extent, as more and more APNs are migrating to specialties. Why? For the same reasons MDs/DOs do. Do they start working for an orthopod or dermatologist, or some other specialist and say, "No, thanks, just pay me what an FNP makes because I am a nurse and I derive pleasure solely from the holistic aspect of healing, not the money." No. I see postings on here all the time for APNs or APN wannabes asking about going into derm, branching into surgery, etc. Money is money, and with more money, you can buy more things.
To say that nurses are immune to greed would be exceedingly obtuse and naive. If you think about it, APNs are already doing it in that they are pushing for equivalent reimbursement with approximately 1/4 or less of the training that a physician performing the same tasks gets.
| | No. 64 |
Aug 06, 2009, 04:19 PM
Re: Doctor Shortage-Who Should Fill the Gap?
You are correct about the greed. I think it can be managed through reimbursement rates and further regulation. I don't see branching into specialty as a problem. It happens in Arizona. The have autonomously practicing APN's in dermatology. The fact is that there are a lot of things in different branches of medicine that they can do autonomously. The part that needs control and regulation are the rates at which they get reimbursed for it. We will still need reform and regulation. I guess the real problem is a third party payor. It just seems to me that if you can get someone to do the routine things for less, people might be able to get a major medical policy and pay for the routine things out of pocket. That would get the third party payor out of the picture and bring down costs for everyone.
| | No. 65 |
Aug 06, 2009, 04:59 PM
Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by mbreaz1 http://money.cnn.com/2009/07/16/news...ion=2009071807
This is a very interesting string of posts. I see a ton of good ideas on here. Some of you should go back to the article link above and put your posts on CNN for all the world to read. I am of the opinion that if we leave NP reimbursements at the lower rates and open them up to autonomous practice, we can acheive exactly what we need to in the way of healthcare reform. Physicians continue to ruin our healtcare system. They are very dysfunctional in their behavior and alomst every reaction they have to cost cutting measures has a way of making it worse than it was before. It sickens me to hear someone say that we need physician input in the healthcare debate. They are a huge part of the problem, and furthermore, they exacerbate the issues that we have with big pharmaceutical companies and insurers. I'm not saying that they are all greedy and don't care about patients at all, but for the most part it is true. They have shaped the system in such a way that they can prescribe more, order more and make more, and they want their cut of the profits from non-physician providers too. And guess what, they get it. After all of that, they want us to cry with them about their student loans, which are proportionate to their salaries (why should we feel sorry for them because of that?). They also want us to cry about their malpractice premiums and give them tort reform, when no other profession enjoys protection from malpractice claims. Then they want us to feel sorry for them because they have high overhead. When other businesses have problems with high overhead, they become inovative and figure out a way to cut it. Why can't physicians find ways to use technology to streamline their businesses and cut overhead? Are they just too lazy to do it or too stupid? I am sick and tired of physicians crying about how bad they have it. If they were so bad off, why would banks be knocking down their doors to loan them money when they won't loan other businesses a dime? Physicians have it better than any other group in this country and they make their money from the health insurance premiums that are driving their patients further and further into mountains of debt. Their only solution is, we need to make more money and have the American public pay off our loans for us. This is ludicrous and there are many better solutions that don't involve paying physicians more or training more of them. We need to start to pressure our state legislators to give us autonomously practicing Nurse Practitioners as a start to reforming our system NOW!
Are you seriously trying to say that all physicians care about is money? If money was the primary motive, going the doctor route is kind of a dumb way to go. It takes years of training and sacrifice before you see any real sort of money and for most people seeking purely money, the opportunity cost of medicine is not worth the payout. As I mentioned in a previous post, physician pay makes up only about 7% of the total healthcare costs, so even reducing their pay to zero won't have much of an effect in terms of savings.
If you think physicians are greedy, I wonder what you think of NPs/DNPs pushing for equal reimbursement as physicians? So they have significantly less training than physicians and yet, they want to recognized as doctors and want to be paid equally as doctors? Hmm, I don't know about you but that sounds pretty money-driven to me. They seem to be lying about their credentials in order to earn more money. So is it okay for me to say that greediness is a big problem in the NP/DNP community and that something needs to be done about even though it's the minority pushing for increased pay?
Regarding your statements on physicians "crying" about malpractice, does any other profession face the threat of a lawsuit as much as medicine does? Does the average businessman face the potential to be sued everytime he interacts with a client/customer? No. There's a good reason to be crying about malpractice. Malpractice insurance rates have been rising for the past decade or so while physician take home pay has been declining for the past several decades when adjusted for inflation.
And regarding the business savvyness of physicians, the business part of medicine is hardly discussed during medical training. I would say a good chunk of physicians have difficulty running a business because they were never taught the fundamentals of running a business. Also, the salaries paid to midlevels is part of the overhead cost; would you be okay with firing these individuals in order to cut down costs?
Please refrain from making blanket statements that have no evidence beyond anecdotes.
| | No. 66 |
Aug 06, 2009, 05:03 PM
Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by mbreaz1 You are correct about the greed. I think it can be managed through reimbursement rates and further regulation. I don't see branching into specialty as a problem. It happens in Arizona. The have autonomously practicing APN's in dermatology. The fact is that there are a lot of things in different branches of medicine that they can do autonomously. The part that needs control and regulation are the rates at which they get reimbursed for it. We will still need reform and regulation. I guess the real problem is a third party payor. It just seems to me that if you can get someone to do the routine things for less, people might be able to get a major medical policy and pay for the routine things out of pocket. That would get the third party payor out of the picture and bring down costs for everyone.
That won't work because the most vocal group of NPs/DNPs is actively pushing for reimbursements at equal rates to physicians. How are you saving money if you're paying the same amount for an individual with lesser training for performing the same procedure a physician does? Switching to increased use of midlevels doesn't necessarily mean cost savings. There's also the chance that there will be more referrals, possibly missed diagnoses that might lead to more expensive care down the road (this depends on the knowledge/experience of the midlevel and I'm not saying that every NP/DNP will misdiagnose), etc. These all add up to more costs.
| | No. 67 |
Aug 06, 2009, 06:26 PM
Re: Doctor Shortage-Who Should Fill the Gap?
Here is your problem, you think that other people who earn what physicians earn don't put in years of hard work and sacrifice to get there, and you assume that every physician is smart enough to make that kind of money in other professions. Let me tell you, it just doesn't happen. CEO's spend far more time making their climb to that position than any doctor ever spends in medical school. Regarding your comments about physician pay making up a small percentage of total costs, I will say statistics always lie and liars always use statistics. Pay is wages and that isn't all of the money that physicians get for doing their job. Furthermore in an industry as big as healthcare, one percentage is a lot, and it could have a huge effect for people who are struggling to pay for premiums. It might even get some people to a point where they don't need a traditional healthcare policy.
I do think NPs and PAs looking for equal reimbursment are greedy, which is why you should read my next post.
Every profession sees a sue happy client everyday. That isn't really the reason for rising malpractice costs though. A very small percentage of doctors account for the overwhelming majority of malpractice claims. The problem is that they aren't dropped from their coverage for bad claims experience. They also aren't treated like every other insured is in that when you are a bad apple, you usually get charged based on your claims experience. The physicians have decided that it is okay to be communists when it comes to their malpractice insurance and spread the cost of the bad apples over every physician. It would seem to me that this is the physician's problem, not the American public's problem. They can solve the problem anytime they like, but instead, they want to cry about it and ask everyone else to fix the problem for them.
Regarding your comments about midlevels being overhead, that just shows that you are very ignorant about business too. Revenue generating expenses are not overhead, and the last time I checked, you can bill for the services of midlevels, right? Sounds like the medical school professors must be doing their students a very bad disservice in not teaching them something about business for that huge price tag they are paying for the education. Nothing stops a physician from picking up something along the way by reading a book, talking to an accountant, etc. to get some business sense about them. They simply choose not to, which is again not the fault of the public.
I have plenty of evidence to back it all up. Sounds like to me that you are the one making blanket statements without evidence.
| | No. 68 |
Aug 06, 2009, 06:44 PM
Re: Doctor Shortage-Who Should Fill the Gap?
I see some mention of PAs clumped in w/ NPs regarding the filler for the primary care gap. These two professions have very different goals. Despite some vocal groups, PAs are committed to physician driven teams- although under that umbrella includes some VERY liberal supervisory arrangements, many of which include an office sit-down with selective chart review every few months.
The movement for universal full autonomy and reimbursement is more common in the NP world.
PAs working under the above described arrangements can do good service to US PC needs without threatening the status quo of physicianism.
And BTW there's no way in hell a med student should be practicing independently.
| | No. 69 |
Aug 06, 2009, 06:45 PM
Re: Doctor Shortage-Who Should Fill the Gap? Originally Posted by TakeBack I see some mention of PAs clumped in w/ NPs regarding the filler for the primary care gap. These two professions have very different goals. Despite some vocal groups, PAs are committed to physician driven teams- although under that umbrella includes some VERY liberal supervisory arrangements, many of which include an office sit-down with selective chart review every few months.
The movement for universal full autonomy and reimbursement is more common in the NP world.
PAs working under the above described arrangements can do good service to US PC needs without threatening the status quo of physicianism.
And BTW there's no way in hell a med student should be practicing independently.
Exactly! So why should an NP/DNP with less medical training than a 4th year med student be allowed to practice independently?
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