Stop the presses, there is an actual bill that has been introduced in the House and the Senate by a bi-partisan group of sponsors that does the following:
- Enhances competition
- Does not screw the poor
- Does not genuflect at the Very Serious People
- Could be signed into law without reservation by President Obama
From Sherrod Brown’s (D-OH) website:
The Pharmacy and Medically Underserved Areas Enhancement Act would allow pharmacists to offer health care services to Medicare beneficiaries in underserved areas – such as health and wellness screenings, immunizations, and diabetes management – by authorizing Medicare payments for those services where pharmacists are already licensed under state law to provide them. Most states already allow pharmacists to provide these services, though they cannot receive Medicare reimbursement for providing them.
Joining Brown in backing the bill are U.S. Sens. Chuck Grassley (R-IA), Bob Casey (D-PA), and Mark Kirk (R-IL). A companion bill was introduced yesterday in the House of Representatives.
If Medicare pays for something, most private insurers will quickly follow. This is a minor, technocratic change to the billing requirements of Medicare. It should slightly increase the pool of Primary Care Providers, it should make disease management slightly more efficient, and it slightly increases access to care while reducing the amount of driving needed.
Is this a Big Biden Deal? No, but it could be, if passed without poison pills, a minor improvement in the status quo for Medicare beneficiaries, while slightly reducing the guild powers of doctors. This is how Congress could work in a rational political environment.
The real reform on attacking the guild powers of doctors has to be at the state level. It should be a goal of anyone who wants to either reduce government spending OR increase access to affordable healthcare for more people to create the most permissive scope of practice and scope of service laws possible at the state level. In practical terms, that means creating laws that give nurse practicioners and physician assistants more autonomy to provide basic services; it means allowing dental hygenists to operate without supervision of a dentist (who mainly collects monopoly rents), it means allowing pharmacists to provide more basic care management services. It means shifting the MDs and DOs to higher complexity cases and away from routine, low complexity cases. This bill does not do it, but it is a step in the right direction.
Ben Cisco
My first reaction is: What did the GOP bury in the bill that screws us?
aimai
I’m pretty happy with my dentist supervising the dental hygienists. Really I am.
Patricia Kayden
Well, this is good to hear.
buddy h
I don’t know. I may be expressing an unpopular viewpoint here. I’ve noticed… varying… degrees of professionalism and knowledge in the pharmacists I’ve dealt with.
I was prescribed the high-dose, once-a-week vitamin D. ergocalciferol. When I picked up my pills, I asked him if it was vitamin d2 or d3. His eyes shifted uneasily, and he replied “Uh… both.” When I got home and read the fine print, I saw that it was 100% vitamin d2.
Another pharmacist kept aggressively pushing the herbal supplements. If you’ve read the news recently about the amount of garbage and actual lack of herbs in the supplements, you’d understand my suspicion.
Another pharmacist, when I asked her if I could take the medication with aspirin, made an annoyed “tsk!” sound, read the informational printout, and then said no problem. She was amused by some of the other warnings, and cracked jokes about them while she was reading.
So I don’t know if I feel comfortable with my friendly neighborhood pharmacist practicing medicine. Especially the ones employed in the large supermarkets. One supermarket, in a brilliant profit-increasing scheme, gave out printouts to each pharmacy customer, advising them to take extra supplements: “your prescription is for high blood pressure? The medication might lower your calcium. We recommend these calcium supplements. Taking this anti-depressant? You most likely are low in melatonin. We recommend these melatonin supplements.’ I can imagine someone at a meeting getting a high five from his colleagues for essentially doubling their profits. “Every time they fill a prescription, they buy supplements from us, too! Ka-ching!”
While waiting for a prescription at CVS, I could overhear the horseplay going on behind the pharmacy counter. Rather disturbing joking and comments. It sounded like a high school locker room. Not a lot of professionalism on display.
This has just been my experience. Others here may have had better experiences with their drugstores.
Richard Mayhew
@aimai: But should it be a requirement or an option? There is a good amount of research that on basic services (teeth cleanings, applying flouride washes etc) having a dentist supervise does nothing besides raise prices, decrease utilization and transfer a couple bucks into the dentists’ pockets. If there is a system in place where the cleaning is down at the lowest level of effective care (the hygenist) who are trained to say “That looks wierd…. go see a dentist…), is that a bad thing?
Punchy
And if my aunt had balls….
This is DOA after the GOP attaches 5-7 riders gutting Obamacare, giving tax breaks to parrot owners, and legislating mandatory gun ownership.
Bobby B.
If Grassley’s involved there;s a drug testing proviso.
buddy h
I notice every time I type a comment with my cat sitting on my lap, it goes into moderation. If I type a comment without the cat on my lap, it immediately goes through.
Does correlation equal causation here?
Roger Moore
@buddy h:
I think you need to perform more testing to be sure. I’m sure your cat will agree with me.
Bill Arnold
@buddy h:
The cat knows when a comment will fail to go through, and sits on your lap to warn you of the impending failure.
catclub
@Richard Mayhew: well put!
Would a supervisory board for dental hygienists that is not entirely made up of dentists make this requirement? No.
This might lead to dentists asking for referrals from hygienists, which would lead to dogs and cats living together. refer madness.
burnspbesq
@Richard Mayhew:
The question you’re eliding is how to ensure that these new classes of practitioners have the necessary training and expertise, and stay abreast of developments in the field. Do dental assistants, pharmacists, etc. have to pass something akin to a bar exam or med boards? Do they have a mandatory continuing education requirement? Etc., etc.
Some of the barriers to entry that guilds erect are worth having.
boatboy_srq
AMA is never going to go for this: MAJOR rivalry between them and pharmacists.
cmorenc
One TOTALLY unnecessary inconvenience about patient visits to most contemporary physician practices is that EVERY SINGLE TIME they require you to fill out a lengthy paper information form, even when you’ve been a prior patient at that practice. ALMOST NONE of them make it easier by providing an electronic way to enter or update that information if e.g. my address or contact info has changes – as to making sure your insurance info is current, they always require your insurance card. YES I understand the need to efficiently get routine background health info information on you and minimize the amount of time skilled staff have to spend face-to-face questioning you to harvest it – but isn’t that what the change-over to electronic medical records is in part for?
I SAY THIS INDIRECTLY WEARING BOTH HATS, since my father was an MD, my wife is an MD, my older daughter is an MD, and my younger daughter is a hospital-based RN. And the physician-and medical-practice side learning and time-investment curve in adjusting to using electronic medical records is considerable, as I’ve witnessed my wife going through it and my daughters talking about it as well. But geez louise, please come into the 21st century and move those forms patients initiallly encounter at practice visits into forms they can easily update with their tablet or laptop, instead of sitting there wasting 20 minutes filling out the same silly form they’ve filled out a dozen times before.
If a non-MD provider would do that, I would GLADLY use them for routine medical services over an MD practice, for that reason alone.
Kylroy
@burnspbesq: They can be, but American medicine in all respects for the past half century has been pretty much “Guilds Gone Wild”. It is possible to have insufficient professional oversight, but when tooth cleaning cannot be performed without a doctor looking over the hygienist’s shoulder, we’re pretty far from that point.
Belafon
@burnspbesq: I have a friend who is a physicians assistant. She is required to get about 100 hours of training every two years by the state of Texas to keep up to date. The physician she works under is required to get eight hours.
Richard Mayhew
@Bobby B.: Honestly, I use Sherrod Brown’s involvement as an indicator that my interests probably aren’t going to get screwed.
Richard Mayhew
@burnspbesq: Yep, they just have different certificates and different accrediting bodies.
Roger Moore
@buddy h:
Given that there are plenty of pediatricians out there advising parents not to get their kids immunized, I don’t think you can limit the lack of professionalism to one profession. There would probably need to be tougher licensing standards for some of the professions if they wanted to operate independently, but it could still be an improvement.
Note: deliberate misspelling in quoted material to avoid spam filter.
Roger Moore
@buddy h:
Now that your comment has been rescued, it appears that one of the professions mentioned by Richard triggers the spam filter. I doubt that there’s any correlation between having a cat in your lap and talking about the profession who works in your local supermarket dispensing medications.
Craigo
Of course there’s licensing and continuing education. A bare five seconds of research revealed this. Are people truly under the impression that just anyone can walk into a dentist’s office and get hired as as a hygienist?
Belafon
@buddy h:
A pharmacy is not a war zone, nor are most places in the US. Professionalism doesn’t require a high tension, no jokes environment.
Belafon
Making comments about medicine, using medical like terms, seems to be a no-no on WordPress.
Roger Moore
@Belafon:
Unfortunately, there are a lot of medicine-related spammers, which makes discussing medical topics a FYWP minefield. We seriously need a better quality spam filter.
Starfish
Guys, some of you are missing the point. These things are to benefit underserved areas.
Various states are allowing various dental practioners to practice more widely due to a) under served areas and b) people not being able to afford dental care.
I am pretty sure that dental hygienists do not have direct supervision in Alaska because there is a shortage of dentists, and the hygienists fill that gap. My bad, they are called dental therapists.
There is also a shortage in Kansas, and there are people pushing this model in Vermont as well.
jl
i hope it passes. From my reading and talking with health care professionals from other countries, this is an approach often used to provide more care more cheaply in many countries. Switzerland, for example, does not have a high doc to population ratio, but has a huge nursing corps, with a very diverse set of skills,ranging from US equivalent of LVN to nurse practioner, as do some other European countries.
dr. luba
@Belafon: Maybe that’s Texas. I am in Michigan, an am required to have 50 hours of CME (continuing medical education) annually by the state. This is in addition to maintaining my board certification, which has annual requirements (reading selected journal articles and passing a test on them, as well as patient care modules) and an exam every six years. I studied for a month for that exam.
Roger Moore
@Starfish:
An additional example is that California just changed the law to expand the kinds of providers who can prescribe drugs for medical abortions. It’s potentially a big deal because it greatly expands access in previously underserved areas.
Buddy H
@Belafon: A pharmacy is not a war zone, nor are most places in the US. Professionalism doesn’t require a high tension, no jokes environment.
Nothing wrong with joking around in the workplace. These were weird, unfunny comments making fun of customers and their medications.
gvg
@cmorenc: Electronic forms for patients is going to start as a terrible mess. I just had a colonoscopy done and the practice tried to make me do preliminary paperwork on line but they picked a set up that was a huge hassle and then didn’t work. After several hours trying and gritting my teeth till I had a headache I sent them a curt email saying send me a pdf to print out and don’t even try to “help” me with the tech issues because I am too mad.
They did but their automated system tried to “remind” me to signup online every few days anyway.
I am concerned about data security for this kind of set up anyway as people have all kinds of flaws in home systems and habits, plus the poor would have to use the public library.
Forget it for now. Doc’s offices aren’t ready yet and they are that expert in computer choices so they are likely to pick out nearly the cheapest, which is not the same as useful. They are kind of gullible to salespeople at this time too and just can’t pick a good system yet. In time word will spread and the choices will get better, but for now stay far away.
Another Holocene Human
@aimai: Me too. Very happy.
It helps that I have a dentist who doesn’t cheat me and doesn’t try to upsell unnecessary stuff. Some people enter dentistry for the wrong reasons (*money*), my dentist is a tooth geek.
I pay good money to have those x-rays every other year because if a do get a cavity, I’d rather not lose a tooth, thank you.
Hygienists are great and people need to get those cleanings but frankly the people who get the least access to dentistry actually are the ones who need the more complicated services that a hygienist can’t help you with because poor nutrition early in life and other health problems have landed them with a plethora of painful and health-damaging problems in their mouth.
Another Holocene Human
@Starfish: I’m sorry, but there are areas which are poor in minerals needed for tooth formation where the native population has just really, really poor dental health AND THEY NEED DENTISTS, like honest to god dental surgery. You know what? The goobermint is going to have to pay for that shit. Stop dicking around and pretending it’s because these folks didn’t brush enough. Just remove their plaque. No. Wrong.
Another Holocene Human
@buddy h: Okay, the real story is that there are still people working behind the Caremark pharm counter with their sanity intact. That’s not an easy thing. (Google it.)
Do you know if you were dealing with PharmD’s, who should absolu-fucking-lutely know their shit about drugs, they study drugs years and know way more about them than doctors do (which is of course why doctors have all the prescribing privileges and big pharma markets to them, knowing doctors are ignorant about drugs, and big pharma and AMA like it that way).
Or did you deal with one of the myriad pharmacy techs, who have a range of training and experience?
I insist on talking to the pharmaCIST if I have a question.
Note: most pharmaCISTs HATEHATEHATE that herbal homeopathic woo woo garbage and the ones working in the chains hate that shit most of all. There are crooks in every profession but most PharmD’s have to reign in the loathing and contempt they have for these products because they work for a chain that relentlessly flogs this utter crap and don’t want to get fired because they told a customer that their childrearing skills leave something to be desired because they would even consider oscilli-scam-i-non over the flu mist.
Another Holocene Human
upps, the cat was off my lap but I said the forbidden words and have been moderated. Ulp!
artem1s
seems like the idea is sound. how it is actually put into practice….? don’t know…
big pharma is not known for restraining itself if it thinks it can grift a bunch of drugs onto the poor and elderly, especially if they know that the taxpayer will ultimately pick up the tab. Also, too many states allow pharmacists moral exception allowances on whether they have to fill scripts as it is. I guaran-damn-tee you there will be some fetus protection language built into this thing. you really think there isn’t going to be a food fight over whether some moral scold has to clean some gay kids teeth because fear of AIDS, jeebus hates them, etc.?
yes, this stuff goes on with hospitals and doctors already but dammit we aren’t just talking about your local little drug store. Imagine the worst that WalMart could dream up to boost their profits with this, and you will get some idea of the potential for trouble.
Starfish
@Another Holocene Human: What do you mean by “pay for that shit?” Do you mean that they should pay oral surgeons to visit that community and take care of them? Or should they pay for these people to have dental insurance?
If you mean that the government should pay for these people to have dental insurance, that does not solve the problem that no oral surgeon wants to live where ever they are.
texdoc
Nurse practitioners or physician’s assistants for common/usual things, sure. But pharmacists? In our hospital, we have the option of leaving management of coumadin anticoagulation to the pharmacist/s. I have to say (as a hematologist) that I have not been impressed.